AN ESSAY 



REMITTENT AND INTERMITTENT DISEASES, 

INCLUDING, GENERICALLY- 

MARSH FEVER AID NEURALGIA. 

comprising, under the former, 
VARIOUS ANOMALIES, OBSCURITIES, AND CONSEQUENCES, 

AND, UNDER A 

NEW SYSTEMATIC VIEW OF THE LATTER, 

TREATIES OF 

TIC DOULOUREUX, SCIATICA, HEABACH, 
OPHTHALMIA, TOOTHACH, PALSY, 

AND 

MANY OTHER MODES AND CONSEQUENCES 

OF THIS 

GENERIC DISEASE. 



BY JOHN MACCULIiOCH, M. D., F. R. S., ETC. ETC, 

PHYSICIAN 131 ORDINARY TO HIS ROYAL HIGHNESS PRINCE EEOPOID 
OF SAXE COBOURG, 



CAREY & LEA 

IS30. 



-t 



i£»* 



Hi l^ 



CONTENTS* 



CHAPTER I. 

Page 

On the ordinary Remittent or Marsh Fever, . .17 

CHAPTER II. 

On the chronic or relapsing and obscure or anomalous Remit- 
tent, .......... 34 

CHAPTER III. 
On the proximate cause of Remittent or Marsh Fever 5 • . 76 

CHAPTER IV. 

On the Cure of Remittent Fever, . . « 80 

CHAPTER V. 
On the Dysentery and the Ohol era, -. . . . .112 

CHAPTER VI. 

On Intermittent Fevers, . . . . . . .120 

CHAPTER VII. 

On the obscure, anomalous, and simulating Intermittents, . 139 

CHAPTER VIII. 

On the Cure of Intermittent Fevers, . - . . . 206 

CHAPTER IX. 

On Neuralgia in General, . . . .... 235 

CHAPTER X. 
On the Neuralgia of the Face, or the Tic Douloureux, . . 23S 

CHAPTER XI. 

On the Periodical Headach, and on Vertigo, . . . 243 

CHAPTER XII. 

On the Neuralgias of other Nerves in various Parts of the 
Body, .......... 863 



>V CONTESTS, t 

CHAPTER XIII. 

Page 

On Sciatica-, ......... 285 

CHAPTER XIV. 

On Questionable Neuralgias, . . . - » . . 295 

CHAPTER XV. 
On Neuralgic affections of the Glands, . 302 

CHAPTER XVI. 

On Neuralgia from Injuries of Nerves, . 307 

CHAPTER XVII. 

QnToothach-, 315 

CHAPTER XVIII. 

On the Rheumatism of the Eye: or the Neuralgic Ophthalmia, 35 S 

CHAPTER XIX. 

General Remarks on the Connexion between Neuralgia and In- 
termittent, 38f 

CHAPTER XX. 

On certain Consequences of Intermittent or Marsh Fever and 
Neuralgia, 395 

CHAPTER XXI. 

On the Cure of Neuralgia in general, ..... 408 

CHAPTER XXII. 

Conjectures respecting the Condition of the Nerves and Ner- 
vous System in the Intermittent and Neuralgic Diseases, . 439 

Tabular View of the Diseases appertaining to Marsh Fever » 
and Neuralgia, .»-...-...■ 471 



PREFACE. 



As long ago as the period of my college studies, my attention 
had been excited by what has been called the Tic douloureux: and, 
even then, I came to the conclusion which every successive year 
has. confirmed, that it was intimately connected with intermittent 
fever, both in its nature and causes; while it therefore became an 
obvious conclusion that its remedies should be sought among those 
by which that disease is cured. 

I could not, then, nor long after, discover that this view had 
been adopted by any one: and finding no support, either from books 
or in the existing profession, for an opinion which, the more I stu- 
died the subject, appeared to involve consequences the more im- 
portant, I have, even till now, forborne to make it public in this 
manner; unwilling to lay claim to the character of a discoverer, to 
pretend to be the only correct observer among the thousands who 
cultivate physic. 

Nor, though I have never ceased to communicate that opinion, as 
well to patients as to my own profession, have I succeeded in giving 
it currency: having thus influenced but a very few of my most in- 
timate medical friends, and even with those, not producing that 
more extended conviction as to the subject at large, which I am 
now about to attempt in another manner. If I also attempted, in a 
brief essay, some time ago, to call the .general attention to the 
whole subject of Malaria and the diseases produced by it, I found 
no better success; since some years have now passed, and no result 
has followed as to any one of the subjects then pointed out for in- 
vestigation. 

My wish was, that some one else should undertake a task to 
which I felt no inclination; and though the great bulk of this work, 
including the essay on Malaria, has been ready more than ten ytears, 
I had no desire to increase the mountain of medical books; to add 
my own volumes to the three hundred thousand, which, according 
to a French Bibliography physic has already produced. But I have 



VI PREFACE. 

waited in vain, and have perhaps done wrong in waiting for others 
so long. 

If, at the present day, there may be a few practitioners who have 
commenced to take the same view, it is unsettled and vague, as it 
is limited and imperfect: while I think that I can generally trace 
it to the propagation of rny own notionsj not very likely to make 
much impression, either on my professional brethren or on that 
body which is called the world. Were a proof of that state of 
medical opinions required, it would be found in the practice as to 
this disorder; than which, even now, nothing can well be more un- 
settled and more tentative; empirical, even where it chances to be 
right, and imperfect even then, for want of general and just views. 
And indeed on this point, nothing can offer a stronger proof than 
the adoption of that practice which consists in the division or ex- 
tirpation of the diseased nerve; an expedient than which nothing 
can be conceived more unphilosophical, while it is also useless; 
and, though now fallen, or falling into disuse, abandoned, not from 
juster views of the nature of the disease, but from want of success^ 
while still regarded with affection by some who no longer venture 
to adopt it. And could this be still doubted, it will be sufficient to 
read what has been written on this disorder, both in professed essays 
and in casual notices: while not to quote these, that I may avoid 
disagreeable criticism, we may find cases, even of very recent date 
considered as inflammation of nerves, and treated by the remedies 
of inflammation, even by persons of the very highest repute in phy- 
sic and anatomy. 

And not only will these proofs be found in the writings on this 
specific subject, but in those which treat of the various obscurer 
diseases belonging to Neuralgia or connected with it: since in not 
one treatise on those disorders which I shall hereafter prove to be 
of this nature, be they palsy, headach, toothach, ophthalmia, or 
what not, do I find the slightest allusion to this cause or connexion; 
even when the recorded symptoms are such that it often appears 
wonderful how the fact could have been overlooked. 

It is far from agreeable to draw the same conclusion from a re- 
ference to persons, even though I forbear to name them: but it real- 
ly is so necessary to produce every apology that can be found for 
a new medical book, that I must, even thus, attempt to establish 
the claims of the present one to novelty; as that quality which, in 
addition at least to utility, forms the only excuse for publication. 
These persons were physicians in extensive practice and of unques- 
tionable educations and, of then% two carried the disease to their 



PREFACE. V/l 

graves, after many years of extreme suffering under erroneous 
practice; one also having been the victim of the disorder itself; 
while the other, after nearly twenty years of the same fate, is still 
a sufferer, and has also paid for his want of knowledge by the al- 
most total loss of his intellects. 

Thus much it appeared necessary to state in the way of expla- 
nation, as to the primary causes of this book. But in the course 
of the original investigations, it seemed to me that I discovered, 
both in practice and in books, many disorders which appeared to be 
luled by the same analogies, yet of which this view had not been 
taken: and thus was I gradually led to investigate the whole wide 
question of the intermitting diseases, and lastly, what soon became 
unavoidable, to inquire into Malaria as the great cause of the most 
conspicuous of those. 

Hence a wide field became at length opened: while I found that 
it would be impossible to elucidate the one subject which had first 
occupied me, to the conviction of others, without bringing forward 
those analogies and that generalization which I had formed for my- 
self, and on which I considered that I had established the doctrines 
here produced. Thus would the very dependence of Neuralgia on 
the febrile intermittent diseases, have compelled me to examine 
into these latter; as, without their history, it could not have been 
elucidated; since the whole, as I trust to prove, form but two de- 
partments of one subject. 

Even thus, this book must have become what it is; including the 
essay on Malaria. But the course of observation on English opi- 
nions and practice, on the great neglect which the febrile diseases 
arising from this cause had experienced, produced other reasons; 
and that there also were, in addition, justificatory ones, I have be- 
come more convinced, by a course of reading which was not entered 
on till long after these opinions were combined into that essay 
which has received from those authorities nothing more than sup- 
port or illustration. 

In assigning these reasons, I have the same unpleasant task to go 
through as with respect to Neuralgia; implying an assumption of 
discernment and knowledge above those to whom I write; though 
it is, in truth, no more than must happen to every one who, in what- 
ever department of science, proposes to convey instruction. Un- 
fortunately, physic is the science in which this is the least endured: 
from causes which I shall leave to the enlightened members of my 
own profession to assign. 

But as far as there is any ignorance in our own country, as ti 



till PREFACE. 



Malaria, or as to the obscurer intermittent disorders which it i$ 
here my sole object to elucidate, it is but just to attempt an apo- 
logy; and this is, that while the modern improvements of England 
have very much reduced the production of that poison, so the rari- 
ty of decided intermittent fevers may have led to ignorance and 
neglect respecting their obscurer varieties; though I know not how 
to find any apology for those who persist in mistaking the fevers of 
marshes for typhus. But thus must tradition, example, habit, go- 
vern the majority in every thing; since all cannot be philosophers 
and observers. Let the value of this apology be what it may, it 
must appear extraordinary to say, that a class of diseases so preva- 
lent as this is, and on which the treatises may be reckoned by thou- 
sands, should now be a subject of obscurity or error to physic and 
physicians in any country. Nor will it appear less confident to 
suggest, that where the causes of Malaria, and of these disorders 
of course, have so long been known, any ignorance could prevail 
as to the locality or nature of those, or any neglect as to the pre- 
vention of the incalculable misery which they produce. Yet I have 
shown that this is most notoriously true of England: while as to 
the diseases thence arising, if it is among ourselves also that the 
ignorance and inattention are most prevailing, even the medical 
profession in other parts of Europe is far from exempt. 

These are remarks which will, I hope, be fully established here- 
after, in as far as they have not already been so in the essay on 
Malaria: and they are therefore sufficient to complete the present 
apology: since, if there is any portion, of which the novelty and 
importance are sufficient to justify a new book in physic, the same 
reasons apply to the whole. 

Nor would any motive but the hope of adding something to our 
recorded knowledge, and of rectifying erroneous opinions and prac- 
tices, for the purpose of diminishing the sum of human misery, 
have tempted me to make public, after this long delay, what I 
would more gladly have received frcrm the pen of some one of 
higher repute and authority; knowing well how little is the impres- 
sion which must be expected from one who has no name in physic 
as a teacher or a practitioner, and who, to his obscurity adds the 
misfortune of being a contemporary, though not a rival; and a con- 
temporary perhaps too much known in other departments of know- 
ledge. This is a situation which, in our own country at least, has 
ever been a condemnation in itself; as if the knowledge of science 
in general was an obstacle to the knowledge of the sciences in par- 
ticular, and as if the powers of observation and reasoning were not 



'B.EFACE. 



faculties of universal application; as fitted to extract the truth from 
one class of phenomena as from another. But if it is the conclu- 
sion of the ignorant, it is perhaps also the conclusion of a commer- 
cial country, where science and literature are alike regarded as 
trades: and being the especial and peculiar conclusion of England, 
we must all submit to what we cannot rectify. 

If I regret this, it is because the effect will be to diminish that 
utility which is my sole object, and to which authority is so essen- 
tial. But I shall have discharged my conscience; since my sole 
object is to diminish human suffering, or to increase human happi- 
ness; a duty which every man owes to society, and, 1 do not speak 
it fanatically, to a much higher Source. It is the especial duty of 
that profession, of which the very end and purpose are but this, 
however lost sight of under other and interested views: and if cir- 
cumstances have prevented me from doing that duty in person, I 
must atone for it thus; convinced that I am here putting into the 
hands of mankind the means of benefits to which my own person- 
al exertions would not bear the most minute proportion. 

This object will, I trust, atone for an anxiety to enforce and 
prove what is advanced, of which I am too conscious not to per- 
ceive that it betrays itself every where, even to repetition and su- 
perfluity. But I hope it is a pardonable one; since depending on a 
conviction that physic can or could save human life and remove hu- 
man suffering where it does not, it is the feeling that life is lost, 
and misery produced from want of knowledge, and that in taking- 
less trouble to prove what I consider right. I should myself be cul- 
pable. Such anxiety will perhaps seem to imply a bad case; a 
feeling of doubt, which is often indeed expressed in foretelling a 
want of success. But that anticipation is the result of experience; 
of the only ground of prescience: since, having failed to convince 
in conversation, I know not why to expect better success in print. 
Yet this is not a question of opinion, but of evidence. If the facts 
are true, and the induction correct, then must others become of 
the same opinion; unless they have, as Locke well remarks of the 
entire world, no ground for opinion but habit and example, and 
disclaim that quality which is presumed to distinguish man from 
other animals. 

The facts have been taken as they occurred; they are the com- 
mon property of physic and physicians, and I believe that they are. 
all admitted. They have been approximated and classed, fallacies 
have been rectified, superfluities eliminated: they are facts still. 
This process has been continued until one leading fact has be 



PREFACE. 



found to appertain to the whole: it has been deemed the essential 
one. This is the induction: if it be a legitimate one, the facts con- 
tinue to be evidence, or the point is proved. This is the usual ma- 
chinery of all science: and by this process have the sciences been 
erected: rescued from the chaos of empiricism, and consolidated. 
Any one may use it: but if it is not available in physic, let it be 
shown why. Physic has indeed been too long empirical; but it 
ought not, and I think it needs not. It has proceeded too much on 
what was apparent; and thence its errors. I have attempted to 
trace a train of analogies, and to arrange a multitude of appear- 
ances under one simple principle: I may have failed; but this is at 
least the right road: and if earnestly followed, it will in time be 
successful. 

To return to some explanatory remarks as to the plan of this 
work. If I have been so minute on the existence and sources of 
Malaria as to have occupied with that subject the volume which 
precedes these two, I cannot think that I have been more full than 
it deserves, when I reflect on the ignorance which prevails respect- 
ing it in our own country, and on the contempt in reality in which 
it is held, as if it were a fiction or a romance, and on the enormous 
mass of evil consequent on such a state of the public mind. Of 
that essay, and of its possible utility in preventing diseases, the 
public will now be able to judge. That the present volume neces- 
sarily refers to it, was as unavoidable as that it depends on it: 
nor could I have acted otherwise, without materially enlarging the 
bulk of the medical portion of this work, while even then leaving 
it an imperfect one. 

With respect to that part which relates to marsh fevers, I 
must observe that it was not my intention to write a treatise on 
those disorders in their decided forms; since, on these, the world 
abounds with books, and often of great merit. Here, I could but 
have compiled, as many systematic writers have already done: and 
while I had no intention of adding a compilation to the heap, I 
had no wish to copy or extract where I could so much better refer 
to the originals, or to compilations without number. Had I indeed 
treated of every disease belonging to this subject as it deserves, I 
must have extended the present volume to many more, as will be 
obvious from the number of disorders which it already embraces. 
The object in this part of the essay, has been to explain those mo- 
difications of marsh fever which have been misunderstood or over- 
looked; that I might rectify the opinions and the practice on many 
matters that have been greatly, and in my own view, dangerously 



PREFACE. XI 

mistaken or neglected. Hence I have made use of the purer forms 
of these disorders no further than was necessary for the attainment 
of this leading object; otherwise than as I have thought it useful to 
otter remarks on them as they occur most commonly in our own 
country. Thus I have even dwelt on the slighter cases or varieties, 
while I pass over the severer ones; and thus also is the chief at- 
tention bestowed on the chronic, the obscure, and the anomalous 
disorders of this nature, since, to explain what has been mistaken 
or unknown, is the object of the work. And as it is to the already 
educated, and not to mere students in physic, that this essay is di- 
rected, I have often passed over matters which cannot fail to be 
known to every one, and which would have swelled a book already 
too large, to an unnecessary bulk. And it is for the same reasons 
that I have omitted to treat of dysentery and cholera, together with 
a large list of disorders endemic in marshy situations; avoiding 
further, those great consequences, the visceral diseases, from mo- 
tives equally obvious. 

I have now one general observation to offer as to the whole of 
these irregular marsh fevers, which I consider an important one as 
far as it relates to the credit which ought to be attached to the re- 
marks on them. I might equally have applied it to the division of 
the Neuralgise, had there ever been any thing written on this sub- 
ject with which my own remarks could at all have come into col- 
lision. 

The entire opinions respecting the former disorders were found- 
ed on my own observations, and must be considered therefore as 
entirely free from previous bias or borrowed theory. Their origin 
was what I have already described; and a space of much more than 
twenty years has been occupied in correcting and confirming them. 
Nor was it till long after they had been generalized into the pre- 
sent form, that I even thought of inquiring into the opinions of 
others, not supposing that my own possessed any peculiarity; while 
the entire essay was written before I undertook that examination 
of authors whence I have since made those additions from which I 
thought I could derive authority or elucidation. 

The coincidences therefore, wherever they occur, I must consi- 
der as a proof of the truth of such views, while I am bound to saj r , 
whether it shall make against this truth or not, that I have been 
unable to find any such general view in any of the authors whom I 
have consulted; and while I see also plainly, that many, of even 
the highest reputation in physic, at all periods, have proceeded un- 
der the errors which I have here attempted to correct. 



Xli 2'EEFACi:. 

Among these, I cannot very well except anyone but Stracl* 
whose work on intermittents, as it relates to this subject, is by far 
the most decided; though, even under his collection of cases, he 
does not appear to have seen the full importance of the subject? 
nor to have formed that generalization which we might have ex- 
pected. That he did not see his way through the entire question, 
is indeed plain; nor, from his work, should I have been able to form 
the present deductions: and when a recent careful writer, Dr. Phi- 
lip, has not drawn the same conclusions, even when largely quoting 
him, it is sufficiently plain that they were not really indicated, and 
that physicians in England have not, to this, day, been aware of the 
importance of the subject: a fact indeed which the slightest exami- 
nation of modern practice will amply prove. 

"With, respect to authorities generally, if those which I have cited 
are not very numerous, they are, I trust, sufficient for the purposes 
of a work which was not intended to be a compilation. It was for 
the sake of giving weight or adding elucidation to what might have 
seemed insufficiently proved or obscure, that I required authorities; 
and if there are not more, it is not that I did not seek them, but 
because they were difficult to find; since my task was often that of 
translating or analyzing confused or misunderstood histories of dis- 
ease, or of seeking under very improbable designations, for that of 
which I was in want; while often therefore compelled also to per- 
form a critical office on what I have borrowed or quoted. 

Such as they are, I hope there are enough for the end in view; 
and if I have neglected much and distrusted more, that will not 
require much apology to those who have read widely in medical 
reading. There are many physicians who will, I believe, agree 
with me in the fruitlessness of seeking among the antiquities of 
this science, for correct information or solid opinions. It is but an 
affectation indeed which attempts to establish medical doctrines on 
the works of the remoter ancients, on Hippocrates, Galen, Celsus, 
and so forth; however interesting, and even necessary in a certain 
sense, it is, to trace the antiquity and infancy of this, as of every 
other science. But to recur to those days for evidence or infor- 
mation, is as if we were to commence our studies of natural his- 
tory and chemistry with Dioscorides, and Theophrastus, Aristotle 
and Pliny, as if we were to found our music on Aristoxenus, or 
our astronomy on Ptolemy. The knowledge of natural history, 
and of physic as one of its branches, was, in those days, nothing: 
it was nothing for nearly twenty centuries after: and though we 
have much reason to blush at the small progress we have made in 



P&EFACi i,. XI 1 1 

our own department of this great study, yet has it been greater in 
the last century than in the whole preceding age of the world. 
" Galen and Hippocrates" will always be valuable to the learned 
in physic: but to hope to learn physic from them, or to build books 
on them, is to be pedantic rather than ignorant; or it is to be igno- 
rant of the truth of the parallel which I have here drawn, and of 
the. history of knowledge. 

If, when I count the pages of this entire work, I am inclined to 
apologize for its length, I am rather more induced to ask pardon 
for its brevity when I recollect the subjects and the diseases which 
it undertakes to discuss. With respect to the mariner of treating 
the medical questions, I know of nothing in physic to prevent it 
from being examined in the usual manner of every other philosophi- 
cal investigation, and in the most ordinary language. The more 
obscure, and the more inductive and conjectural the philosophy of 
physic is, the more does it demand every simplicity in the mode of 
discussion that we can apply to it. And if technical forms of rea- 
soning or technical phraseology cannot always be avoided, they can- 
not be too much shunned; not merely because they corrupt the 
English tongue, but because words and phrases thus become the 
substitutes for ideas, cheating us with the semblance of reasoning, 
and "signifying nothing." With such language, it is easy to 
write books on all subjects, not on physic merely: but to translate 
them into intelligible English, is a test which he who loves to think 
that he has acquired knowledge, must not apply. 

But we cannot always avoid what we would wish to shun: for as 
it is the fate of science to begin with conjecture and assertion, as 
its infancy is the reign of the imagination, so is physic yet in that 
very infancy, wandering about in its own fairy land. Ptolemy and 
Theophrastus were indeed the predecessors of Newton and Lin- 
naeus, but the Newton of physic is yet to come: and he who knows 
this study best, knows best also, that it is not the metaphysicians 
and the jurists, the Platos, and the Kants, the Tribonians and the 
Heineccii, alone who have appropriated to themselves the language 
of vacuity and chaos. If this science abounds in bad observation, 
in imaginary experience, and even in positive mala fides, so have 
the laws of philosophy and logic scarcely yet found their way into 
it. The language of truth is simple and brief, but that is not the 
language of physic. Its words have meanings, and the same words 
have always the same meaning: but this is not the language of phy- 
sic. The language of error is multitudinous, variable, vague and 
unsteady; and this is the language of physic. If there be a philo* 



XI V PREFACE. 

sophical reader who doubts this, if there be a logician, a man ac- 
customed to evidence, who has not read medical books, let him read 
even the most celebrated and be satisfied. 

But he who is now the philosopher in physic is also a Pythagoras 
while he does not perceive it. There is a dogma, not to be ques- 
tioned: a principle to which the facts are to be referred: and, once 
invented and laid down, it is, as in the Catholic Church, an article 
of faith, never again to lie questioned; till a fresh sect separates, 
to enact its own equally infallible laws. This might be as inoffen- 
sive as the eternal fitness of things or innate ideas, did it not in- 
terfere with human life and happiness. But to borrow the expres- 
sion of a learned friend on the subject of legislation, the physician 
is like Nebuchadnezzar: he dreams, and death is the sentence of 
him who cannot divine what that dream was. 

Let me make one further explanation and finish. The object of 
this essay is to propose some changes of opinion, and to recommend 
some alterations of practice, as to certain disorders. The very at- 
tempt therefore implies a disclaiming of former and present opi- 
nions and practice: while in desiring to establish that what is dif- 
ferent, and proposed, is right, it becomes necessary to prove that 
what was and is, was and is not right. But as opinions are the 
opinions of persons, and as practice involves their actions, no as- 
sumption of wrong as to the state of medical science or practice, 
can be made without implying wrong in those by whom it is culti- 
vated and administered. Hence the unavoidable criticisms on the 
science and the art, must always appear to involve those cultivators 
who form the profession: while the inconsiderate will imagine a ge- 
neral personality to be contained in that criticism which is as pure- 
ly impersonal as it is unavoidable. 

To end. If, in the preceding volume, or essay, I have preferred 
the Italian term Malaria to Miasma, so I have here adopted the 
term Neuralgia; because, while the associations attached to words 
become almost insurmountable, I consider that the trifling French 
term, Tic Douloureux, has long been an obstacle to the knowledge 
of these diseases, from its inveterate association with the face ex- 
clusively: since it would be as difficult to convince the people at 
large that a disorder under this name should exist in the finger or 
the toe, as that it might be attended with very little pain, or be an 
inflammation, or even a "fit of the Ague." 



CHAPTER 1. 



On the ordinary Remittent or Marsh Fever. 

If it were my purpose, as it is not, to compile a general ac- 
count of this disease from authors, I know of none in the whole 
circle of physic on which I have read with less satisfaction. He 
must labour with no small discrimination, who would, from me- 
dical works, extract any rational account of the immediate 
causes of the disease or of the real condition of the system un- 
der it, who would discover any intelligible and consistent me- 
thod of cure, who would even be always certain that it is of this 
disease and not of contagious fever that he is reading; as he 
must also possess talents at reconciling or balancing evidence 
which are not the lot of all. It is more likely that he who ima- 
gines he has done this, is an ex parte judge; seeing the ques- 
tion by his own one light, or cutting the knot which the patient 
investigator could not untie. 

If that is true of this disorder as it is known to us, and if it 
is partly owing to that confounding, in practice, of marsh fever 
and contagious fever which I have criticized in the essay on 
Malaria, it is not less so, if from different causes, of the dis- 
ease in that form of greater severity which it assumes in hot 
climates. And while, in these varieties, I have no personal ex- 
perience, I feel that I have as little right to doubt or criticize, 
as I have, but too often, little reason to place confidence. For- 
tunately, it is not of great importance as to the present essay; 
of which the object is rather to notice the diseases of our own 
country, and to point out obscurities, which, however known 
to many physicians, are not generally so, either to practitioners 
or patients; while it is a further object to class together some 
disorders which appear to have been as much misplaced as mis- 
understood, and which, misplaced as to their causes and charac- 
ters, have been necessarily treated in an erroneous manner. 

As the head, unquestionabty, of that great class of diseases 
originating in Malaria, it was impossible, in any view, to omit 
the Remittent Fever. It is the most important link of the phi- 
losophical chain, and, further, it is connected with others as 
their apparent cause: or, that disordered state of the body which 
commences as remittent, may terminate in almost any other mo- 
dification of the diseases of Malaria; probably in all. 

3 



IS ON REMITTENT FEVER. 

But, even as a simple and original disease, the common re° 
mittent fever requires notice here. It is usual with physicians? 
and very naturally, perhaps properly, to treat of diseases in 
their more perfect forms; but a perfect disease is far less com- 
mon than an ill-defined one, a highly severe one than a more 
mild. And while, in these two sets of instances, the obvious 
symptoms may vary exceedingly, it happens, even daily, that 
the unreasoning practitioner or the bad observer, unable to re- 
fer the disease to its usual description, becomes at a loss, or falls 
into grievous errors. Hence arises the necessity of describing 
the varieties of a given disease, as far as it is possible to classi- 
fy such varieties or simplify their description: and this becomes 
peculiarly necessary when such varieties are subject to be mis- 
taken for some other disease where a different kind of treatment 
is necessary. 

Hence it is that, in this variety of marsh fever as well as in 
the intermittent, my purpose is chiefly to notice that which is 
either obscure in itself, or least generally known; proposing 
both these divisions of the present essay as supplements and ad- 
ditions to the numerous treatises already existing, rather than as 
systematic descriptions in themselves. If there are authors, as 
there are some, who have casually noticed such modified forms 
of those diseases, they have not yet been all brought together 
under one consistent view; nor, what is perhaps even more im- 
portant, have they been associated into one system with the still 
more obscure, local, and partial disorders with which I here 
purpose to. prove that they are connected. 

There scarcely appears a reasonable ground of doubt in the 
present day, that the cause of remittent fever in its perfect form 
is the application of Malaria. Cases, however, do occur, un- 
der the most apparently careful observation, while they swarm 
in medical writings, which would prove that various other 
causes do produce it; such as mere heat, errors of diet, fatigue, 
cold, mental affections, or other sources of debility. But every 
one of these is an accessory cause of many other disorders; so 
that the same may be true here also: while if it has been proved 
in the former essay, that Malaria is more easily generated, and 
transported further than common opinion had decided, if it is 
often present when unsuspected or neglected, it is still likely 
that it is the real exciting or productive cause, and that all the 
others are but casual or assisting ones 

This question I have, however, examined under all the lights 
I could throw on it in the preceding essay: to recur to it 
here, would be mere repetition, when I consider that, to en- 
lightened medical readers, this is rather the second volume of a 
single treatise than a complete work, and that, without enor- 
mous repetitions, I could not have rendered this portion inde- 



ON REMITTENT FEVER. 19 

pendent of the former. All therefore which I can here permit 
myself to say is, that I have attempted to prove that all the fe- 
vers of any moment which are not produced by contagion are 
the effects of Malaria, very often, perhaps very generally, in 
our own country overlooked; and that while these two leading 
classes constitute the great mass of fevers throughout the world, 
those which arise from the other causes here alluded to, are pro- 
portionally very small in number, and of very little moment as 
diseases, from their trifling power on the body. But if I have 
said that such causes are, by themselves, of little influence in 
producing fevers, that opinion can but be given as including a 
high probability; since, in physic universally, we have not yet 
arrived at such accuracy as to enable us to decide on any exclu- 
sion in such a subject. 

One only real exception seems well grounded. It is that 
cause which depends on habit. It is a practical observation, 
that, not only in intermittent, but in remittent, at least in our 
own country, causes in which Malaria cannot be conceived im- 
plicated, do in reality reproduce, if they do not produce, both 
kinds of disease; or that the accessory cause, united to habit or 
to facility in receiving or suffering diseases', is sufficient to ex- 
cite those fevers. Thus does the remittent, like the intermit- 
tent, become at times even habitual; renewed, even over and. 
over again, for years, though the patient should not quit his 
chamber; and thus bearing an analogy, remote it is true, to con- 
tagious typhus, where one relapse at least can take place with- 
out the application of a fresh contagion: unless indeed, in this 
case, the patient's own contagion, applied in various obvious 
ways, may be the cause in question. 

It is a fact, formerly noticed, that the intensity or severity 
of remittent is commensurate to the heat of the season or cli- 
mate, provided the soil be a wet and a vegetating one; and 
therefore the quantity of disease is in a direct ratio of either 
the quantity or the quality of the Malaria, or both. M. De- 
veze is but one of many who consider the quantity as con- 
stituting the real difference. There are at least as many more 
who presume on essential differences in the quality of the poi- 
son: but to what purpose do we compare opinions when we are 
in want of facts? Unless, indeed, those which I formerly no- 
ticed when speaking of Malaria should be admitted as argu- 
ments in this case. 

As in all cases of physic, however, either of these conclu- 
sions would require some modifications, and might even imply 
somewhat more; even to disputation. The subject of the dis- 
ease itself, the human body, may be so affected by collateral 
causes in these instances, as to suffer more or less from the same 
strength or action of the primary cause. And while this is 



20 ON REMITTENT FEVER. 

thought to be proved from the effect of mere heat on the biliary- 
system in the case of pure cholera, if this disease be indeed the 
consequence of mere heat, it is easy to understand how an ag- 
gravation of the power of Malaria might accrue from the com- 
bination of such an effect with a simple fever. And thus may 
the greater power of any other of the secondary causes in this 
case, produce a severity of disease which, from neglecting this, 
might be attributed to a greater virulence or quantity of the 
primary one. This is a question, however, which I took occa- 
sion to examine in the essay on Malaria, or in that which is the 
first volume, properly, of this work; so that I need not repeat 
the doubts or arguments there suggested, as I could but go over 
the same ground again. If it is a necessary question here, so 
was it one there: and while that is true of so much more, I can 
only regret a separation which was forced on me, and trust that 
many of the readers of these purely medical volumes, have mas- 
tered the preliminaries without which much of the present ones 
will appear obscure. 

It is there also, in the last chapter, that will be found the de- 
tailed argument, to which 1 have just alluded, respecting the 
causes of fevers; attempting to prove that many of the received 
ones are imaginary, and that the great, nearly the exclusive 
cause, of every conspicuous fever that is not contagious, is Ma- 
laria. That argument was there most needful; as on its value, 
is very much built the necessity of those precautions which that 
volume teaches and inculcates: that it was needful here, is no 
less obvious; while I must take it for granted that it has been 
read, and, I hope, admitted. 

There also have I explained, in the eighth chapter, what re- 
lates to the influence of climate and season, as of other collate- 
ral circumstances in the production of fevers or epidemic pe- 
riods, and in modifying the characters of those; so that on this 
point also, which I should otherwise be here compelled to speak 
of at some length, I must assume that my reader is in a state of 
information. 

On this subject I shall only here add, that barely to enume- 
rate these recorded varieties, would be, in itself, to produce a 
long chapter of little better than repetitions; details without end, 
which must be consulted in the abundant originals where they 
are recorded. Should any reader not have travelled further 
through this species of reading than even in Rush's writings, 
he will, I am sure, readily excuse me if 1 do not even abridge 
what, though abridged, would form no small volume; what, as 
it relates to every country and every epidemic, now constitutes, 
not volumes, but shelves of volumes. 

To pass to other matters, it is a question of some importance 
what are the comparative effects of Malaria in this case, on the 



ON REMITTENT FEVER. 2l 

natives and on strangers, or visiters; and it is one of some little 
intricacy, or on which at least there are many contradictions, 
real or apparent. Such as -these are, they will be generally 
solved by distinguishing between what, for want of better 
terms, may be called the chronic and the acute action of Ma- 
laria. 

What the diseases arising from this poison are, and what their 
effects on the natives and inhabitants of unhealthy districts, have 
been detailed in the preceding essay. In this place I must add, 
that, setting aside what may be called the chronic effects, and 
the disorders exclusive of fever and dysentery chiefly, it is not 
the fate of the inhabitants to suffer acutely from the latter in 
every season; while it is plain that if this were the case, exter- 
mination must be the speedy consequence. The more usual 
cause is, that after one, or perhaps more, severe fevers, this dis- 
ease becomes chronic and intermittent; persisting uniformly in 
some cases, and, in others, ceasing during certain periods, whe- 
ther annual or of longer duration, to be again renewed in a si- 
milar manner: a few becoming freed from it after a certain num- 
ber of years, and at a period of life seldom under fifty, while a 
greater number carry it to that grave, of which the time ranges 
for them between thirty-five and fifty, if they have escaped as 
far as the former period. Such is the nature, and quality, or 
extent, of this acquired habit of resistance by the natives of an 
unhealthy district; or, in vulgar language, the " seasoning,' 7 
which is also acquired by emigrants, if in a much inferior pro- 
portion: though I have stated a definite and perfect case, from 
which very many must necessarily vary, but with which they 
can be compared. 

Thus such seasoned persons, or natives, escape many of the 
acute fevers which seize on emigrants and visiters; but in sea- 
sons of peculiar epidemics, they also suffer similarly; their 
powers of resistance extending only, as it would seem, to a cer- 
tain point: and hence the mortalities so often recorded, which 
mark peculiar years, involving all in a common destruction. 
These considerations, varied according to climates, countries, or 
circumstances generally, which it would be tedious to detail, 
will explain the chief facts here concerned: while among mi- 
nuter particulars which it would be endless to examine, it must 
be remarked that in certain climates, intermittent, or a chronic 
state of fever with facility of recurrence being more rare than 
in others, such a fever, once undergone, may be the pledge of a 
long continued security. I shall only remark here, to prevent 
mistakes, that convinced by the evidences produced by Pym 
and others, I view the security against the " yellow" " Bulam" 
fever, produced by the same cause, as of a different nature, in 
asmuch as I must believe that this is a separate disease from the 



22 ON REMITTENT FEVER, 

"yellow," marsh, or remittent fever. And the security in 
question is, in certain parts of Flanders, Holland, and elsewhere, 
acquired even by young children; so that having once passed a 
certain ordeal, they may lead a life of tolerable health, and even 
attain old age. 

If it is on emigrants or visiters therefore that the marsh fe- 
vers, whether in autumn or spring, as remittent or intermittent, 
exert their chief action, so is it important to remark that those 
are most susceptible and suffer most, who emigrate, or are tra- 
vellers, from healthy and mountainous countries: while the na- 
tives of flat, moist, or marshy ones, even should they not have 
undergone such fevers, are comparatively secure. This has 
often been remarked in France and Italy; and it is said to have 
been very conspicuous in our .army at Walcheren: while it is 
plain that it offers a valuable hint respecting the selection of 
troops for peculiar services; but one, it is painful to say, which 
like much more as to this department, has not been considered 
or acted on as it deserved. On analagous grounds, I must also 
remark, that residence in a hot climate produces a similar power 
of resistance, or a " seasoning," even though the person in ques- 
tion should not have undergone that constitutional change which 
disease seems to produce. 

Yet there is a remark to be added here which is of conside- 
rable importance, if true; as I see no reason to doubt, when it 
is that of an experienced and careful observer, Pym; namely, 
that no residence, however long, in a hot country, produces 
this security if the winters are cold, or if the climate is not 
truly tropical: such periods of cold appearing to nullify the ef- 
fects of the intervals of heat, and the important conclusion as 
to military service being, that Gibraltar, or any other hot coun- 
try of Europe, does not operate as a "seasoning" for troops 
which are destined for the West Indies. 

Such is the state of the leading question; but there is still a 
general contradiction remaining which I must attempt to explain; 
since he who should read on this subject in the hands of other 
writers, might come to a diametrically opposite conclusion : a con- 
clusion indeed which might be formed from many parts of this 
very essay. This relates to the susceptibility of fever, com- 
monly of intermittent, in those who have already experienced 
the disease: a susceptibility far too notorious, since few of those, 
among many others, who suffered from the fever of Walcheren, 
have escaped its returns in a chronic form on a fresh exposure 
to the causes. And this, in truth, is the fate of the unfortunate 
residents in unhealthy districts; since it is by continued or re- 
peated exposure to the causes, that their fevers are renewed, 
and since the only cure in most cases is a migration to a healthier 
country. 



ON REMITTENT FEVER. 

The explanation seems simply to consist in a difference be- 
tween the susceptibility for an acute and for a chronic disease? 
as I have already hinted, at least for the majority of cases: the 
facility of undergoing the former being decreased, while that 
of renewing the other is augmented: though I should also add, 
that as far as my own observation and reasoning go, I do not 
consider the doctrine of " seasoning,'' as to acute fevers, so well 
established as to deserve implicit reliance, and that wherever the 
disposition exists, it would be an act of prudence to avoid any 
such exposure, notwithstanding the experience and opinions 
which I have detailed. I need scarcely add, I presume, that, 
as happens respecting many other diseases, there are persons so 
constituted as to be unsusceptible of marsh fever in any form; 
and what is not less familiar, that certain races of men are far 
less susceptible than others, even independently of any presumed 
" seasoning" which they may have derived from climate. 

On the former fact, the resistance offered to Malaria by cer- 
tain persons, or from certain unknown causes, or at some periods 
of time and not at others, I have one fact which deserves quoting, 
because of its extremely precise character as a philosophical expe- 
riment, and because it would not be easy to find others of a si- 
milar nature. A young man was recommended to acquire an 
ague, from some fanciful project for removing a previous chro- 
nic disorder, and was sent into one of the worst parts of Kent 
for that purpose. The attempt was made by standing in a moist, 
but not watery, ditch, of bad reputation, for a certain number 
of hours every evening, so that the level of the ground was 
near his face. The project could not have been much better 
chosen; but it required nine days of perseverance before the end 
was obtained. It is a fact which, whatever other conclusions it 
may produce, will also serve to show how little we can prove a 
negative with respect to the power of any given spot in pro- 
ducing Malaria, in consequence of its failure in exciting disease; 
as it will scarcely, I think, be now argued that the poison re- 
quired nine days to operate. 

Another preliminary question remains before I enter on the 
history of the fever itself, and it concerns the time which inter- 
venes between the application of the poison and the production 
of the disease; and whether that be remittent or intermittent fe- 
ver, is of no moment, since these are, truly, but modes of one 
disease. That there are some singular opinions on this subject 
which I am unable to explain, is true of so much more belong- 
ing to the history of these disorders, that it will excite no sur- 
prise. 

If my own frequent observations show that fever may be in- 
duced within half an hour after exposure to Malaria, and that a 
single inspiration, or the space of a veiy few seconds, is amply 



24 ON REMITTENT EEVER. 

sufficient for the purpose, this is also an opinion most decidedly 
stated by many French and Italian physicians whose experience 
and acuteness will not be questioned. It is equally the opinion 
of other observers, not physicians, and therefore without the 
bias which might be suspected in such cases: of military, and 
chiefly of naval men, whose observations have been founded on 
the momentary and transitory effects of a breeze of wind, and 
especially of a land wind blowing off to sea. In France and in 
Italy, to confirm this, instances are known and recorded, of la- 
bourers dying instantaneously from merely sitting or lying down 
on the ground, and of others who from looking into a ditch or 
drain, have been struck dead by that poison which, of course in 
a minor degree, would have merely produced a fever. Lind, 
also, whose authority stands high, describes the instant seizure 
with nausea and delirium, as many others have done; so that 
respecting this part of the question there needs be no dispute. 

The more difficult point to determine is, to how long an in- 
terval after its application the action of this poison can be de- 
layed: and here, to quote Lind again, this limit is extended by 
him as far as twelve days. As I have had occasion to say else- 
where, it is not believed by any one of whom I know, that Ma- 
laria can, like the matters of contagion, he attached to a substance 
of any nature, and thus conveyed to excite its diseases; and the 
observations necessary to determine this interval are not there- 
fore entangled; while it is plain that, to make them truly, the 
patients must, after a momentary or brief exposure, be com- 
pletely removed from all the original causes. It may be ques- 
tioned whether this has often been carefully done or recollected; 
while it is certain that from a very frequent or general neglect 
of the obscurer spots or causes producing Malaria, such persons 
may often have been unwarily exposed to them, thus easily 
leading to unfounded opinions on this subject. And as many 
of the recorded ones have been derived from facts occurring 
where armies remained on a given spot of ground, though the 
individual was not a second time exposed to the more obvious 
cause, it is evident that fallacy is easily introduced into the ob- 
servation: particularly when what has been formerly said on 
the propagation, as~weli as the production of this poison, is con- 
sidered. 

Whatever the truth may be in this case, the present doubts 
are not expressed without as ample an examination of evidence 
as it has been in my power to make, and that examination con- 
sisting in attempts to ascertain at what most distant period re- 
mitting fever has appeared in ships after leaving the shore and 
thus getting out of the influence of the land winds. At first 
sight indeed, the opinion in question would appear to be con- 
firmed by many of the cases which I have obtained from the 



ON REMITTENT FEVER. 25 

log-books of ships of war, of which I shall however name but 
one, as it will be sufficient for the purpose. In this instance, 
a remittent appeared among the crew when on the coast of Af- 
rica; when the vessel put to sea on a cruize, notwithstanding 
which, however, other men became sick in succession during 
the space of twenty days, after which no further cases occurred. 

It is plain that this is the kind of experiment almost alone by 
which the fact of a long dormant state of the poison could be 
proved: but unfortunately it still leaves room for doubt, from our 
knowledge of the fact noticed elsewhere, that a remittent will 
become, or perhaps produce, in any given individual, a conta- 
gious typhus, under confinement; so that in this instance, as in 
other analogous ones, the fact may have been of this nature. No- 
thing but extreme accuracy on the part of the ship's surgeon in 
ascertaining the nature of such a fever, can render such cases 
evidence; and unfortunately, as I have more than once remarked, 
practitioners at large have seldom exerted themselves in making 
this distinction as it ought always to be made; since in every 
season, and almost in every place in our own country, to this 
very hour, the autumnal and marsh fever is called a typhus and 
considered a contagious disease. And when what I have for- 
merly said respecting the production of Malaria by bilge water 
is recollected, it is plain, that, on this ground also, the above 
observation does not determine the question in doubt, and that 
it will always be a case very difficult of examination, from the 
uncertainties which must exist respecting the purity of the facts 
in evidence. 

But whatever my own doubts may be, I am bound to state 
the opinions of others, yet not without the remarks to which 
they seem exposed. Many physicians or surgeons, both Eng- 
lish and French, have said that even after six months, many 
soldiers who had been at Walcheren and had escaped the fever 
there, were seized with the same disease in other countries; as- 
serting also that the poison had remained during that time dor- 
mant in the constitution. Pym is one of those who thinks thus, 
and so I imagine does Blane; while Bancroft believes that the 
intermittenrs of spring are (he produce of Malaria received in 
the previous autumn. Baumes, resembling Lind, limits the 
term to fourteen days; but Ferrus, coinciding with the former, 
relates in proof, a case of a soldier who having escaped at Wal- 
cheren, was affected with this fever six months after, on the 
Niemen; as there is also a case quoted in evidence, where an 
English regiment became attacked in the same circumstances in 
England, after eight months. 

It may very naturally be asked why a fever produced on the 
Nieman should not have been produced by it, or why any such 
fever, any where, must necessarily be that of Walcheren, or ot 

4 



26 ON REMITTENT FEVER. 

any other former residence, since fevers of similar characters 
may occur in many places: or why, because an English regi- 
ment which had formerly been at Walcheren suffered from fe- 
vers in Spain, these should not have been the produce of Spain. 
These questions are obvious; while, on physiological grounds, 
we must be troubled to conceive a poison of this, or of almost 
any nature, lying dormant in the body so long. It is much 
more reasonable to conceive a new disease and a new poison, of 
which the presence was overlooked; or, as perhaps sometimes 
happened, that the disease had formerly been suffered, though 
in a slender form, and easily neglected among so many cases 
and difficulties; thus producing that susceptibility which would 
mark one set of men rather than another as the victims of a new 
cause. I need only add, to these objections, that disorders of 
the spleen are frequently produced, without very obvious fever, 
and that as these give a susceptibility of Malaria, many of the 
cases in question have probably been of this nature. Why we 
should believe, with Bancroft, that a vernal ague should have 
remained dormant from the preceding autumn, when we daily 
trace the cause itself, or the exposure, and the consequent dis- 
ease, it would be rather difficult to say. Let me therefore leave 
this subject to the opinions or prejudices of others; for thus will 
it probably be determined, by each for himself; as is generally 
the fact in such cases. I may proceed to the consideration of 
the disease itself. 

The symptoms of pure, or simple remittent fever, are too fa- 
miliar to physicians to require detail, being that of every feb- 
rile disorder. And while I may refer to a hundred books for 
what I could not describe better, I must really also refer to them 
for such a history as should be a full one; since in so many of 
the recorded cases or epidemics, the variation in number, order, 
intensity, and superfluity of symptoms is such, that it would 
require no small space even to abridge what ought not to be 
abridged. Headach, lassitude, pains of the limbs, general debi- 
lity, derangements of the prima? viae, diminution of the intel- 
lectual powers passing to morbid excitement and delirium, aug- 
mentation of heat, with thirst and disturbances of the pulse or 
circulation, which may be mere acceleration, or more, include a 
sketch of the ordinary symptoms; while the heat, being tem- 
porary or paroxysmal, terminates, or not, in perspiration, and 
is sometimes preceded by cold, though the proper cold rigour 
is rarely found in this fever, after the first paroxysm, often also 
forming the first symptom of the attack. In some cases, the 
heat and cold occur in a very irregular or disorderly manner; 
but while I merely pretend to give a sketch, since to medical 
readers the bare term fever is sufficient, I need not detail these 
variations. Nausea or vomiting may exist also in the simplest 



ON REMITTENT FEVEK. 27 

disease, but are more commonly depending on local affection; 
while the state of the tongue, always febrile, varies with the 
quality and nature of local disease in the primse vise. 

If I here forbear to give an accurate detail of the history of 
fever, so, for the more complicated forms of this disease, and 
for pictures of the more severe cases, as for the history of epi- 
demic varieties, I prefer a reference to the endless authors on 
the diseases of hot climates; but I may mention, that while an 
undue, and apparently a morbid secretion of bile is the most 
conspicuous and common local affection, producing sometimes 
what is emphatically called the yellow fever, so the brain and 
other organs, and above all, the stomach and the bowels, are 
often found affected by inflammations, modifying materially the 
symptoms, and also demanding important modifications in the 
practice. 

From these circumstances, variously modified and combined, 
and from others possibly, consisting in the nature of the season 
or climate, in the previous condition of the patients, or even in 
the very nature of the Malaria itself, arise those endless varieties of 
this fever, not merely as it relates to individuals but as to whole 
periods of epidemics, which have filled volumes, and of which 
a mere abstract would make no small book. Important they 
assuredly are; since, while they so often account for the discre- 
pancies of medical writers, not merely as to the history of these 
fevers, but as to the practice adapted to them, so they are the 
necessary causes of great diversity in that practice. But where 
even a systematic writer on fever alone, is compelled to confine 
himself to a general abstract, and to refer to authors for these 
varieties, I shall be still more easily excused if I follow the 
same example; while I also refer to such systematic writers as 
Fordyce, Clutterbuck, Philip, and many more, even for that 
minute general history which it would be a mere waste of the 
reader's time to repeat. 

It is necessary, however, to notice that characteristic symp- 
tom whence the disease derives its name. This is a remission 
or diminution of the intensity of the several febrile symptoms; 
occurring once in twenty-four hours, but exceedingly variable, 
not only in the period of its arrival, but in the length of its du- 
ration and in the degree of relief which the symptoms experi- 
ence. In severe modifications, and not unfrequently also even 
in mild cases, it either becomes difficult to mark this remission, 
or the fever appears to be thoroughly continuous, or is actually 
so, as far as any fever can be; though I should remark that over- 
sights are not uncommon on this subject, from the occurrence of 
the remission during the night, or at a time when the physician 
is not present to observe it. It is important, however, that it 
should be watched and ascertained; as the salutary exhibition. 



28 ON REMITTENT FEVER, 

not only of medicines but of food, often depends materially upon 
it; while it often can be discovered by due inquiries into the 
feelings of the patient during our absence, into the state of the 
appetite or desires at particular periods, and into the hour at 
which sleep is obtained. It is commonly by a gradual prolon- 
gation of this interval of remission, that this variety of the fe- 
ver of Malaria becomes an intermittent; and this leads me to 
consider the terminations of this disease, though for a fuller de- 
tail than I think it here useful to indulge in, I must again refer 
to the numerous well-known writers on the diseases of hot cli- 
mates, as vvell as to those who, like Fordyce and others, have 
written fully and specifically on the subject of fevers. 

I must still, however, remark somewhat more pointedly, as 
to the question of remission, that even among the most accu- 
rate and able observers, we find ample histories of this fever, 
more properly perhaps therefore called marsh fever, where it 
has been perfectly continuous, at least as much so as a typhus 
fever ever is; while in such cases, the additional presence of pe- 
techias and the other associated appearances, renders it some- 
times utterly undistinguishable. Hence in part, among other 
remarkable instances, the almost endless disputes respecting the 
Bulam yellow fever, so well known to every physician; and 
hence also disputes, even more numerous, if less conspicuous, 
respecting various epidemics occurring in military and naval 
service; disputes often including errors which have furnished 
misapprehended evidence as to the very existence of contagion, 
How intimately this question concerns us, even at home, I 
shall often here have occasion to point out, as I have indeed al- 
ready done more than once in the essay on Malaria; since from 
an unfortunate blindness as to the existence or presence of Ma- 
laria or its causes, added to want of reflection among the mass 
of routine practitioners, and perhaps not a little aided by the 
now popular and vulgar use of the term typhus, it is almost the 
invariable usage, not merely of the people but of the generality 
of practitioners, to give this term to every continuous marsh 
fever; and not only so, but, more inexcusably, to apply it even 
where the most ordinary discernment and reflection would indi- 
cate a true remittent. 

That fever is often regulated by certain critical periods, so as 
to terminate preferably on the third, fifth, seventh, ninth, ele- 
venth, fourteenth, seventeenth, and twentieth days, has been 
ascertained by abundant observation; but as to such other mi- 
nutiae, or more questionable effects, which may belong to a si- 
milar influence, whatever it be, I must refer to Balfour and 
other writers. The same authors also, will describe those cases 
of excessive severity, unknown to our more fortunate climate, 
where the disease terminates in death within the first davs; but 



ON REMITTENT FEVER. 29 

in our own country, I know not from experience that it ever 
thus terminates sooner than the seventh: yet if death at that 
early period is unusual, except under very improper treatment, 
we may often witness the entire recovery, or the sudden and 
decided transition into intermittent, after a very few paroxysms; 
in rare cases, even after one. Three weeks may probably how- 
ever include the much greater number of terminations in reco- 
very when the disease submits to the law of the critical days; 
while it is not uncommonly protracted to six weeks; and even 
in cases where its extreme mildness might have led us to expect 
an earlier solution. Where this law does not seem to exist, we 
can assign no period for the recovery, as we can fix on no par- 
ticular time when it is to be fatal; but I may remark that except 
in the case of relapse, the protraction of remittent beyond six 
weeks is a very uncommon occurrence; though, in my own ex- 
perience, this long duration is not extremely rare. 

The termination of remittent is often perfect, and in every cli- 
mate; while, asl have just remarked, it sometimes subsides into 
an intermittent. This intermittent also frequently disappears 
after a few paroxysms, and even without remedies; as, often 
also, it is easily removed hy the well-known medicines. But in 
other instances, it not only becomes durable but inveterate, as- 
suming any one of its numerous modifications. This event is 
decidedly much more common in the tropical and hot climates 
than in our own; while it seems to be peculiarly conspicuous in 
certain countries or situations, preferably to others, where the 
cause of the difference is not obvious. Some parts of China 
have been noted in this manner; and it has also been asserted of 
some particular situations in Greece, in Italy, and in Spain; 
while, if my information is correct, the intermittents that fol- 
low the fevers of Moldavia are particularly noted for their in- 
veteracy, as well as for the peculiarity of their attached symp- 
toms. A fuller enumeration of this kind might easily be made; 
but it is better to refer, as before, to the well-known works, for 
that which would serve little purpose, thus separated from the 
entire histories of peculiarities in this disease, or of the varieties 
to which marsh fever is subject Yet I must also remark, that 
in this case, it would seem as if certain situations, or peculiar 
varieties of Malaria, or else perhaps the fevers which they pro- 
duce, had an especial power in generating, not simply an inve- 
terate intermittent, but a habit of acquiring, or a facility in re- 
newing the disease, which often renders it the inheritance of 
what may remain of life. Walcheren, I need scarcely say, has 
been a noted instance of this nature; and that the cause has beer- 
deemed to consist in the formation of certain durable organic 
derangements, is a question which I shall have occasion to in- 
quire of hereafter. 



30 ON REMITTENT FEVER. 

As remittent may terminate in intermittent, so does it pro- 
duce, or end in, the local and painful affections of the nerves 
which may be ranked under the general term Neuralgia. This 
is a subject however which will find its more proper place under 
that head; as it must then be brought forward as a proof of the 
common origin and connexion of these two apparently most 
distinct diseases, and of the general dependence on Malaria, of 
the several disorders which I have treated in this essay. 

The production of paralytic affections by remittent, or its 
termination in such disorders, is a subject somewhat complica- 
ted; and thus, while often overlooked or mistaken, or else de- 
nied, it cannot be named without entering into some necessary 
explanations and limitations, that, if possible, the truth, and 
nothing more, may be stated. 

That marsh fever does act directly, itself, or its generating 
poison, on the nervous system, is proved by the state of apo- 
plexy or profound coma with which the attack is sometimes 
ushered in; a fact common in Italy, and known by the name of 
febbre larvata; though, in this case, mere intermittent may also 
be the supervening disease, instead of remittent. That, in these 
fevers, the affections of this nature have been attributed to local 
diseases of the brain, I know; and such events may doubtless 
occur. But this does not explain the cases in question, where 
the affection of the brain is instantaneous, following directly the 
application of the poison, even before fever is produced, and re- 
sembling that which occurs from the application of other poi- 
sons, whether to the lungs or the stomach. 

Farther, as it is the effect of Malaria to produce the local af- 
fections of particular and single nerves, either with supervening 
or present pals)?-, or without either, while the brain is not af- 
fected, and while no local inflammation or other disease of that 
organ can be supposed to exist, from there having been no pre- 
vious fever, it is plain that Malaria does exert a power of some 
kind on the nervous system directly; on the whole, or on more 
or fewer of its parts, even to a single point in the minutest 
nerve. 

Thus then the larger paralytic affections, such as hemiplegia, 
or palsy of a leg or an arm, consequences occurring from inter- 
mittent as well as remittent, are probably direct actions on the 
nervous system; while, as paralytic diseases, more or less dura- 
ble or extensive, do also follow that merely painful affection of 
the nerve which was the produce of Malaria, the whole of 
these effects seem to be concatenated under one general cause or 
action. 

And in this manner we can probably also explain that dimi- 
nution of the powers of the intellect, often proceeding, even to 
perfect idiotism, which sometimes follows severe or long conti- 



ON REMITTENT EEVER. 31 

nued remittents; and which has been known to influence the fa- 
culties through life; though, in this latter case, there may some- 
times be organic diseases in the brain itself, the produce of local 
inflammation during the fever. 1 am still more inclined to con- 
clude, however, that, whatever the diseased state of the brain, 
as of a single nerve in the analogous cases, may be, the cause of 
this injury to the mental faculties, as of all the paralytic affec- 
tions, is not a previous inflammation, in the vulgar sense of that 
term; because it will be remarked by those who can forget the 
prejudices connected with their practice and derived from their 
hypothesis, that these fatuous and paralytic symptoms or disor- 
ders are peculiarly apt to affect those patients in whom bleeding 
has been misapplied; just as the same mistaken practice often 
causes the merest local affections belonging to Neuralgia to ter- 
minate in the same m miner. 

This particular subject must necessarily come under review 
again, in treating of the local affections of the nerves produced 
by Malaria; but I cannot terminate it at present without offering 
one suggestion. The local application of cold sometimes pro- 
duces complete palsy, as is well known; and it seems to me that 
the hemiplegia of labouring people, often attributed to drinking 
spirituous liquors, is sometimes at least, and probably very ge- 
nerally, the consequence of sleeping on damp ground, particu- 
larly after fatigue. And in such cases it also appears, that, 
however the action of Malaria may here be suspected in certain 
climates, simple cold, in a country free of Malaria, is sufficient 
to produce the effect; just as a general torpor of the whole sys- 
tem, particularly in feeble or old people, is often the result of a 
long-continued exposure to a low temperature any where. 

But if Malaria does produce direct apoplexy, as it also often 
brings on a comatose state which is exceedingly durable, both 
in remittent and intermittent, and if also it produces, not only 
local and similar effects on single nerves, but complete hemiple- 
gia, it will be most necessary to inquire whether some of the 
cases of paraplegia or other palsy, especially as occurring in cer- 
tain climates and in campaigns, are not instances of the same na- 
ture; since, whether our practice in such a disorder should be 
different or not from the treatment of palsy produced by simple 
cold, the philosophy of physic cannot fail to be improved by dis- 
covering causes and assigning distinctions. 

The last class of diseases following remittents, and appearing, 
whether really so or not, to be their produce or to form their 
termination, are the visceral glandular affections, comprising 
chiefly those of the liver and the spleen. As the supervening 
dropsy is generally esteemed but an ulterior consequence of 
these, though much oftener, I believe, the direct produce of in- 
flammation than it has been thought, I shall not here notice it 



32 ON REMITTENT FEVER. 

further. Or rather, I must entirely avoid treating of this dis- 
ease, in whatever mode it is produced by fever or by Malaria: 
not that I consider its history to be thoroughly understood, far 
from it, or the practice as to its several varieties disentangled 
and clear; but because, should I attempt to treat every disorder 
connected with this principal subject, I should write a treatise 
including a large portion of an entire system of physic. 

It is evident that, in certain cases, the remittent has existed 
before there are any appearances of the glandular diseases; while 
it is common for those to show their symptoms most strikingly, 
after the fever has subsided or disappeared. Hence the not un- 
natural conclusion, that the injury of the gland is the produce 
of the febrile action; although it has also been concluded re- 
versely, that the glandular disease is the proper cause of the fe- 
ver. Thus diversely do different hypotheses cause men to look 
at one object. 

Is it not possible also that they may sometimes be indepen- 
dently associated? The question is a difficult one, but there are 
facts which would seem to prove that this is the truth, at least 
in many cases. I observed formerly, that the liver affections of 
India seemed to be the produce of its Malaria, and the apparent 
substitutes for that which, in some other situation, is simple re- 
mittent, in others again, intermittent; though if they have at- 
tracted most attention in that country, it seems, by the report 
of many physicians, that they are, perhaps, not less common in 
Africa; while, if they occur also in the western tropical climates, 
it is less generally and less independently. Here then, acute 
glandular disease at least, would be an independent effect of 
Malaria; if indeed it be certain that the attendant fever is not 
truly the marsh or remittent fever, modified by this inflamma- 
tion, or else mistaken, in consequence of the prevalence of an 
overwhelming local symptom. Thus also, through France, 
Italy, Sicily, every where, it is common to find, not merely 
single instances, but a whole population, suffering from glandu- 
lar diseases in their worst forms; while no fever is present, and 
while also, in many cases, it seems to be ascertained that no fe- 
ver has preceded, or that there has at least been no severe re- 
mittent or intermittent as the cause. I feel it necessary to make 
this limitation; partly from the difficulty of procuring accurate 
information as to individuals, and partly from the fact, that if 
glandular affection shall be judged the produce of fever exclu- 
sively, there are, in such countries, in justification of this opi- 
nion, intermittens in abundance, of a character so slight as 
scarcely to excite the notice of a people to whom the disease is 
endemic; and where, as everyone suffers alike, it is scarcely 
conjectured that such a thing as health exists, or that all the 
world is not in the same condition. 



ON REMITTENT FEVER. 33 

But, however different physicians may decide this point, whe- 
ther from their previous views or from more extensive observa- 
tion than has fallen to my lot, I have met with numerous in- 
stances in this country, of diseased spleen at least, and that to a 
considerable extent, where patients, sufficiently observant of their 
healths, in a few instances very remarkably so, and some being 
even medical men in practice, could pronounce with confidence 
that no previous fever of any nature had ever existed, neither 
remittent nor intermittent; though at the time of applying for 
advice, there were present some of those obscurer derangements 
of health, or local nervous affections, which I have here classed 
under the diseases of Malaria. 

Thus the subject must rest for future examination; as I do not 
think even this last evidence completely satisfactory, and feel 
no inclination to found my own belief, at least, on any thing but 
evidence: considering that the opposite tendency is now, as it 
ever has been, the leading obstruction to the progress of medical 
science; tempting by its facility because requiring neither labour 
nor talents, levelling all men, and, in every sense, ruinous to the 
progress of knowledge. 

Such is a sketch, as far as it appears requisite, in the work 
which I have proposed to myself, of the general character and 
results of common remittent fever. I need not point out the 
differences or resemblances between this disease and the fever 
produced by contagion, or the typhus, nor again repeat, after the 
numerous times that I have noticed it in the essay on Malaria, 
how often the one has been mistaken for the other, and with 
what consequences: while a full inquiry on this subject in all its 
bearings belongs to a regular treatise on fever; an investigation 
not wifchin my plan or limits, nor, for my peculiar purposes, 
necessary. For what I have thought fit to pass over, I can re- 
fer to a thousand authors: but to name titles which any man 
can read in the Bibliotheque des Sciences Medicales, would be 
the extremity of affectation. 

Yet I may perhaps here add to what I formerly said, that the 
inveterate and common error to which I have just alluded, has 
probably been the chief cause of an opinion lately promulgated 
with some energy, namely, that no fever is contagious. It is 
perfectly true, that when we really examine the great mass of 
fevers occurring throughout the country, they are not so; but 
because wrong has been committed on one side, we must not 
double that error by running at once into the opposite extreme. 
I believe, myself, that in the present state of society, in Eng- 
land at least, or wherever the lower orders are in a state of de- 
cent comfort, contagious fever is in reality very rare, even 
among them, whatever it may be in Ireland: but to assert that 
there is not such a thing as contagious fever, is to discredit evi- 



34 CHRONIC AND OBSCURE 

dences as numerous and incontrovertible as science, or human 
affairs, have ever produced. And let us not forget also, that 
even in proving the fevers in question not to be contagious, 
there is but little gained, unless it is also believed that these are in 
reality marsh fevers, or fevers of Malaria, whencesoever arising: 
since, to rest in some vague notions of a fever which is not con- 
tagious and does not belong to this class, is to deprive ourselves 
of the means of prevention, and, further, to incur the hazard of 
a faulty practice, from misconception of the character of the 
disease. 



CHAPTER II. 

On the chronic or relapsing and obscure or anomalous remit* 

tent. 



The preceding sketch of the common marsh or remittent fe- 
ver, has been given, not as a proper or full history of that dis- 
ease, but as an indispensable basis towards the examination of 
those varieties which may be comprised under the general title 
of this chapter. To explain those, has been the sole reason for 
introducing, at all, this branch of the diseases produced by Ma- 
laria; as the entire purpose of this essay is, not to repeat what 
is already known or ascertained, but to explain what is consi- 
dered as obscure, or as having been neglected or mistaken, 
Had I not given this previous sketch, I should not have had a 
point of reference for the varieties in question; and must often 
have introduced, as a subject of comparison and illustration, 
what did not precisely belong to the question under immediate 
consideration. 

To begin with a general view, it is by no means uncommon 
to find, in our own country, to which, as far as my own proper 
descriptions and opinions are concerned, I shall here invariablj^ 
limit myself, a modification of fever which is, often, little no- 
ticed, and very generally misapprehended, while it is a source 
of great distress. This, as it appears to me, can be referred 
only to the remittent; bearing the same relation to the definite 
and severe disease, which the slight but permanent intermittent 
does to the equally severe and regular ague. If this peculiar 
varietv is sometimes sufficientlv severe and marked to be es- 



REMITTENT. 35 

teemed a fever, it is far from uncommon for it to be so slight as 
to pass for hectic, for what is called debility (a term without 
meaning) or for ill health, or delicate health, terms equally con- 
venient to cloak ignorance; while not unfrequently also, it is 
characterized by the no less convenient phrase nervous, oreven 
brings on the unlucky patient the charges of hypochondriasis or 
affectation. 

To be now more particular, there is a fever not uncommon 
among us, to which the popular term nervous fever is applied 
most accurately when it is of a slender nature in regard to its 
symptoms, however durable it may sometimes be. This is a 
disease which, with unpardonable carelessness, as it appears to 
me, systematic writers, and Cullen among others, have often, 
perhaps always, confounded with contagious fever under the 
name of Typhus mitior. It is not, in general, the produce of 
contagion, and it cannot be communicated. As far as my own 
observations indeed go, I should say that it never was a conta- 
gious disease, nor produced by contagion: but I must not refuse 
assent, absolutely, to the assertions of other observers of repu- 
tation, and am therefore willing to believe that there does exist 
a contagious or typhus fever of this peculiar and slender cha- 
racter: a possibility indeed to be inferred from the very slender 
varieties of plague which are sometimes known to occur. Yet 
when I grant this, I must still express my doubts that a real ty- 
phus, produced by contagion, and of this mild character, can 
ever be a long-continued disorder. In cases where there ap- 
pears to have been a certainty of contagion, with a mild fever 
consequential, this has been short as well as slight; and the same 
is true of the mild plague. Durability, or the property of pro- 
longation, seems to be a peculiar character of marsh fever under 
all its forms: and until an unequivocal case of contagious fever 
thus mild and thus durable is produced, I must continue to be- 
lieve that all long-continued, or often relapsing fevers belong to 
the disorder under consideration. 

If I have hazarded these remarks on the typhus mitior of 
Cullen's arrangement, I am not less inclined to offer similar 
suggestions as to his Synocha and Synochus ; observations 
which are a somewhat more direct continuation of that investi- 
gation which has preceded in the essay on Malaria, and to 
which I must here refer. I cannot pretend to say, that there 
is not a pure inflammatory fever, as it is called, unattended by 
local inrUmmation, which is neither the produce of contagion 
nor Malaria, and which may be the produce of mere colcl or 
of the other assigned causes which I formerly discussed in the 
essay alluded to; but I believe that the disorder so called is 
very frequently a fever of the remittent family, and producpd 
by the same causes; a terminable attack, whether naturally, or 



36 CHRONIC AND OBSCURE 

through remedies, of a disorder which is as various in its cha- 
racters and duration as any one in the catalogue can well be, 
This opinion will at least be supported by those foreign writers 
hereafter to be noticed, who consider that the intermittent may 
consist but of one paroxysm, finding also its natural termination, 
without remedies. With respect to the Synochus, it is not to 
be denied that a contagious fever will begin with symptoms of 
one order and proceed to its termination under the very op- 
posite ones: but where the marsh fever is so perpetually con- 
founded with this species, and when it is so general a character 
of remittents to commence with a class of symptoms requiring 
bloodletting, but soon terminating in very different ones, it is 
to be suspected that the very loose term Synochus has often 
been applied to these, as it, not improbably, was by the noso- 
logist himself; whose ideas, practically, as to fever, do not ap- 
pear to have been very definite, and whose " First Lines," in 
numerous places, whatever their medical reputation may be, 
offer most unsatisfactory specimens of reasoning, as well as of 
the statement of facts, to him whose notions of philosophical 
writing have been derived from other courses of study than a 
medical one. 

I have already said, that we cannot yet decide absolutely, 
what causes besides Malaria may produce such a fever as that 
under review; for, notwithstanding what I have formerly ad- 
duced in disproof of the other reputed ones, it must be recol- 
lected, that our present knowledge of causes in physic is really 
very imperfect, and that the question itself is a very difficult 
one. It is as bad philosophy as it is too common, to hasten to 
conclusions; and, in physic, it is far too general a practice to 
forget the pursuit of truth in the chase of an hypothesis. But 
while I showed, in the discussion to which I have here referred, 
how easily deceptions may creep in as to these imagined causes, 
I have also there most fully proved that Malaria is far oftener 
present than has been imagined. And if the fever in question 
can sometimes be clearly traced to that cause, its whole charac- 
ter, when carefully studied, is that of remittent fever in its pure 
and acknowledged form, and in its severer modes. Its duration, 
and its tendency to critical periods, are the same, and it is rarely 
if ever without a diurnal remission; which nothing but neglect 
will prevent the physician from tracing, though it often does 
require a minute attention, on account of the want of contrast 
between the paroxysm and the intermission, arising from the 
feebleness or small severity of the symptoms. Further, it often 
terminates in an intermittent as slender and obscure as the ori- 
ginal disease: while it also is not unfrequently followed by the 
local affections of the nerves, such as periodical headach, tooth- 
ach. intermitting rheumatism, and even marked Neuralgia. 



REMITTENT, 37 

And further yet, while it displays characters which should 
always have prevented it from being confounded with conta- 
gious fever, it is apt to become habitual, or to recur in frequent 
relapses, even through a long course of years; a circumstance 
never occurring in contagious fever, and on which I shall have 
occasion to dwell presently. In this it resembles the analogous 
intermittent; as in this also, it copies, in some measure, the 
much better marked remitting fever; while, the methods of 
cure will be found to correspond, and while further it is not 
unusual for it to be attended by glandular visceral affections. 

Such are the arguments for considering this " low fever," "fe- 
ver on the spirits," " fever on the nerves," (for by these names 
also, as well as nervous fever, is it known,) as a modification of 
remittent, and probably as a fever of Malaria: and if these are 
not satisfactory, we must perhaps erect a new genus for it; since 
it can never be truly classed with the only other durable fever 
that we know, the fever of contagion. Let physicians at least 
say how we shall dispose of a fever of this character which does 
not belong to one or other of the two leading classes; since I 
must confess that I know not where to place it, and am unwil- 
ling to go on as we have hitherto done without ideas; satisfied 
with a term, and, once possessed of the word , fever, inquiring 
no further what are its causes or what its analogies. Physic 
will never thrive thus; for thus has no science ever thriven; 
while, if I have not here truly pointed out its analogy, let some 
one else attempt it; yet through ideas and not words, by means 
of better evidences than those which are here brought forward. 

And it is far from unimportant that this point should be clear- 
ly understood; as it is only thus that our practice can be justly 
regulated: while it is most certain, that by mistaking it for other 
diseases, the sufferings of the patients have often been, and are 
daily and every where, materially aggravated. And if the cause, 
the original one, be Malaria, as in the case of acknowledged re- 
mittent, whatever the causes of the relapses may be, we thus 
acquire the means of prevention; of which, as long as we mis- 
take its nature, we cannot avail ourselves: while further, if I 
have here proved that such relapses are often, probably in the 
far greater number of cases, brought on by incautious exposure 
to the cause, through ignorance of that as The Cause, and through 
ignorance of the places which produce Malaria, we have also 
acquired the means of curing, as it may be termed, a disorder 
notoriously troublesome in its relapses; since, in this case, pre- 
vention is cure. If those who still doubt will watch it carefully, 
they can scarcely, I think, fail to be convinced, if at all capable 
of observation and free from prejudice; while some further ar- 
guments may perhaps aid in deciding their judgment. One of 
these is, that it is among those habitual diseases included under 



3S CHRONIC AND OBSCURE 

the vague term ill health, which are the produce of low and wet 
situations or of some of the soils formerly described as produc- 
tive of Malaria; and I think this will appear the fact to those 
who will bestow a careful attention on the patient's history as 
to residence, past or present, and on the soils connected with 
this which I have stated in the former essay as the causes of fe- 
ver: while I need not say that such an investigation demands 
care, very particularly where aught is to be trusted to the pa- 
tient's own recollections. Another argument is, that its rela- 
tion to the marked or severe and terminating remittent, in slen- 
derness of symptoms and in the frequency of its recurrence, is 
precisely that which intermittent, equally slender and equally 
returning, bears to a limited and severe intermitting fever; while 
I may lastly add, as a proof of its cause and return, that if it is 
especially subject to relapses in low and wet situations, as well 
as indebted for its very existence to those, so it is best cured, 
and especially when relapsing or repeated, or chronic, by change 
of air; that is, by change to a drier air as it is usually termed^ 
or, what is the fact, by removal from its causes; a circumstance 
explanatory, alike, of the value of travelling and of migrating 
to watering-places. 

I have here frequently regretted the necessity of commenting 
on the obscure cases of disease recorded by physicians, and there 
are few men better entitled to this apology than Hay garth: but 
the obvious utility, and even necessity of such a proceeding in 
a work of this nature, is the best apology that can be offered to 
a sensible man. In the Medical Transactions of the College, 
this able physician describes as inexplicable, a peculiar state of 
permanent debility, enduring even for years, and without very 
marked disease of any kind: and he notes it also as being com- 
mon in young females, and in the opulent ranks of society. I 
must not say absolutely that this was or is the disease here in 
question: but unless where I have readily traced this not un- 
common disorder to the abuse of purgative medicines, and oc- 
casionally of bloodletting and cupping also, (a circumstance no- 
ticed in a future part of this essay,) numerous instances of this 
precise nature, or at least agreeing precisely with Dr. Haygarth's 
description, have been decidedly proved to be the variety of re- 
mittent, or fever, which I am describing; while in the greater 
number, the duration has extended to two or three years, or 
even more, with intervals indeed of tolerable health, in spite of 
all common remedies. I shall be surprised if others, hereafter, 
taking this view of what cannot be uncommon in any physi- 
cian's practice, do not in future arrive at the same conclusion: 
but I shall submit this conjecture to the reader's own judgment 
when he shall have perused the present chapter. 

It will now be necessary to describe, as far as can be done, 






REMITTENT. 30 

the symptoms of this fever, and most particularly when those 
are most slight; since these are the very cases where erroneous 
observation is most common, and is followed by equally erro- 
neous practice. 

This disorder may be found, and not un frequently, with 
scarcely any marked symptom except mere muscular weakness: 
a debility on any attempt at exertion, which seems unaccounta- 
ble, inasmuch as it occurs in persons, even in youth, and appa- 
rently strong, and is not very obviously accompanied by any 
proper febrile symptoms. At times, not even the appetite seems 
affected; and here, almost necessarily, the result is, to suspect 
the state of the patient's mind, or his moral dispositions, ra- 
ther than his health; to suppose, for example, as I have often 
seen, that a soldier is "shamming, 7 ' that an opulent female is 
indolent or affected, or a studious or professional man hypochon- 
driacal. 

Yet, let an acute physician watch this disease, and he will be 
convinced that it is a disease, and moreover a fever. It com- 
mences and terminates like the remittent when best marked; 
and when it appears to be prolonged for months or years, as is 
sometimes the case, it will be easy to see that it has had inter- 
vals of cure, generally of self-cure, and relapse; and that, to 
each relapse, there is a period of weeks, not very uncommonly 
of six, while the intervals vary from one or two to any given 
number. Further, either the patient or the physician, or both, 
must be very inattentive if they do not discover that the parox- 
ysm of extreme debility is fixed; that it is, in fact, a paroxysm, 
let its length be what it may, and that there is a diurnal period 
when it diminishes, or where the patient, who, possibly, could 
not stand, on getting up in the morning, is enabled to exert, 
and even to enjoy himself at night. 

Hence, as to some cases, at least, the truth of, as well as the 
reason for, a very common remark, that midnight is the nervous 
patient's holiday; though there are unquestionably many cases 
of nervous affection, and even of periodical returns and inter- 
missions in this complicated class of disorders, which do not ap- 
pertain to a remittent type of fever, or perhaps to any fever. 
The particular case here quoted, is one, of course, where the 
paroxysm attacks in the morning and the remission is at night; 
but while the periods are necessarily various, so are the results, 
as to the complaints, appearances, or sufferings of the patient. 
I shall presently trace some others of the more marked of these 
modifications. 

I have assumed here that pure debility may be the sole symp- 
tom of a remittent; but it would have been more correct to say 
the sole obvious one, since it is rare but that the patient at least, 
if an attentive observer and a good reasoner, and if at the same 



40 CHRONIC AND OBSCURE 

time free from the morbid influences of the imagination, will 
not discover other indications of a febrile remittent disease; 
however the physician may overlook them, from neglect, or 
perhaps from ignorance, or system; or, as may also happen, 
from want of sufficient opportunities for personal observation. 
He moreover who would discover what he cannot see, by cross- 
examination, must know well what questions to put and how to 
present them; or he may remain ignorant, from assuming a wrong 
course, or else gain the very answers which he has suggested. 
A leading question is too often as deceptive in physic as in legal 
procedure. 

The obscure symptoms which I am now to point out are those, 
as might be anticipated, which, whenever they become marked, 
are also easily discovered; and which, as they gradually multi- 
ply, and become also more conspicuous, indicate a more severe 
disease, gradually passing into a form so distinct, that the cha- 
racter of true remittent fever can no longer be denied to it, even 
by the most prejudiced. And these gradations of severity, if I 
omitted to adduce them just now as an additional argument in 
proof of the true nature of this disease, are, in reality, among 
the strongest evidences of its argued origin and cause; since it 
would not be difficult for any attentive physician in tolerably 
extensive practice, to collect a series of his own cases, rising in 
exact gradation from the simplest debility to the most perfect 
and defined remittent fever. 

I noticed that the appetite was sometimes not affected; but, 
even in the slightest cases, a careful observation will show that 
it is partial and irregular, or, in common language, capricious. 
The fact in this case is, that it vanishes during the paroxysms, 
returning in the interval; a term which I choose in preference to 
intermission; while the common inaccuracy of observation as to 
this fact, or a diversity of judgment as to the condition of the 
appetite, arises from a coincidence, or the want of it, between 
the conditions of the fever and the usually established hours of 
eating. He whose paroxysm includes the hour of breakfast, 
may be unable to eat in the morning, while he can dine; whereas 
a paroxysm extending till night, may make him suppose that 
his appetite has entirely vanished; when, did he attempt to dine, 
or sup, at midnight, or at some period of the night, should that 
be the interval of health or abatement, he would cease to make 
this complaint. And thus it is also, that w 7 e meet with cases 
where the appetite seems unaltered amid considerable disorder; 
because, in these, the paroxysm returns at night, and the days 
form the intervals. Hence a rule in the cure to be noticed here- 
after, which relates to the hours of eating; and, as will also be 
then shown, on similar grounds, which equally refers to those 
of sleep. 



REMITTENT. 41 

It is barely possible that in these slight cases, the condition of 
the tongue may be healthy, or nearly so, and that the primas 
viae may also be in a state of regular action. More commonly, 
both are affected in modes too familiar to require further expla- 
nation: but these, as belonging to so many other disorders, are 
seldom of any value as diagnostic symptoms; not seldom also 
misleading a bad observer, and being considered the cause of 
disease, of which they are merely the consequences. In the 
whole catalogue of ordinary practical errors, I know few indeed 
more common than that which views a sluggish state of the 
bowels as a primary disease, sometimes also a consequence of 
theoretic disorders of the liver, instead of considering it what 
it really often is, the produce of a febrile state, belonging, either 
to this fever or to some other initiative and similar cause. Nor 
is it difficult to account for this error, vulgar as it is common; 
since it is the consequence, partly, of seeing, in a disorder, no- 
thing but obvious symptoms, and partly of that empirical prac- 
tice for which England is so celebrated, and which, while it 
tends to blind the judgment, can, from its facility, be conducted 
by any one; while I need not tell the medical reader to whom 
we are indebted for its present influence and abuses; an influence 
and abuses which, whether they are now increasing or diminish- 
ing, are convenient to indolence, by superseding the necessity 
of thought or investigation, and by reducing the whole practice 
of physic to an empiricism, to which I know not that its entire 
history can produce a parallel example. 

I feel no hesitation in saying that fevers of this character are 
a very general cause of the chronic and common derangements 
in question; and have no doubt that there are many physicians 
who are aware of this, and that many more will come to the 
same conclusion when they shall re-examine the disorders of 
this character under the present views. And consequently, 
that while these are symptoms of fever, not primary affections 
and causes of a febrile state, as is the common error under the 
system which I have been censuring, they may appear to con- 
stitute the sole disease, if the other symptoms are slight; just as 
mere debility does in other cases: ready therefore to mislead, 
even an attentive physician, and much more certainly the cause 
of false judgments in those of a reverse character. In this fe- 
ver, however, as is to be expected, such derangements become, 
in certain cases, more marked; or, as the disease at large ap- 
proaches to the more perfectly defined or more severe remittent, 
there occur all those circumstances which, as belonging to ac- 
knowledged fever, I need not dwell on. 

What perhaps may appear most remarkable, is the state of 
the pulse; and it is the symptom, above all others, which mis- 
leads unobservant practitioners. There are persons who cannot 

6 



42 CHRONIC AND OBSCURE 

conceive a fever without an accelerated pulse: whereas, even in 
severe cases of remittent, the pulse often gives no indications of 
any disorder, or the very reverse of what such practitioners 
would have anticipated. At the very most, the periods during 
which the pulse is affected are sometimes so very transitory, 
that it is a chance if the physician should be present at the 
time; while it is an observation seldom required from patients 
themselves, though, in such cases, perhaps improperly neglected. 
Thus it will happen, that in point of velocity, or of character in 
every way, the pulse may be natural during the far greater por- 
tion of the day, while for a period of an hour, or even far less, 
it may undergo that very peculiar change, consisting in asperity, 
or hardness, or diminution of size, or feebleness added to acce- 
leration, generally, but not invariably, and sometimes indeed 
quite the reverse, which marks the commencement of the pa- 
roxj^sm, or the whole properly febrile state; and which is all 
that we ever find of what may be called the cold stage, or of 
the hot one; since these are, commonly, scarcely distinguishable 
in this fever, and since the former in particular can scarcely be 
said to exist at all in many cases. And if this state takes place 
in the night, as does, and not unfrequently, happen, in spite of 
the well-known remark that the majority of quotidian attacks of 
fever occur in the day, it may be as unobserved, or even denied, 
by the patient, as it is unknown to the physician. It is not 
therefore wonderful, should it happen, that, finding no proper 
or obvious febrile symptoms, hearing of nervous fever and ner- 
vous disease, and witnessing perhaps only nervous symptoms, 
dyspeptic ones, derangements of the bowels, debility, one, or 
more, or all, the practitioner who is influenced by a wrong sys- 
tem, or is without any views at all and is merely guided by 
terms, should conceive himself in possession of a " nervous" 
patient: acting accordingly, or doing nothing right, with per- 
haps a good deal that is wrong. 

Here also I must remind the reader, that even in well-marked 
remittent fever, there is often a period of the day in which the 
pulse becomes slow, frequently falling below sixty; while it is 
not unfrequently also full, as if under coma, and while this state 
is further attended by actual sleepiness approaching to coma, 
and not seldom, if this is not present, by lowness of spirits or 
melancholy. The same occurs in the slighter disease under no- 
tice, and in different degrees; while being also what is called a 
nervous symptom, it tends still further to mislead the negligent 
or ignorant practitioner; him who is guided by a correlative 
comparison of names and receipts, terms of diseases and the an- 
tagonist terms of medicines. 

The diseased state of mind may however exist at two distinct 
periods of the paroxysm, and under two different states of the 



KEMITTENT. 43 

pulse. Under the accelerated or contracted one, it is a state of 
peevishness or irritability, attended by the feeling of despon- 
dency or not: or it is a modification of the great leading passion 
anger, which together with fear, the equally inclusive and prin- 
cipal passion, forms those deranged states of mind appertaining 
to hypochondriasis, which appear under so many modes and 
modifications. And if under the full and slow pulse, it is com- 
monly simple or passive despondency, or, in extreme cases, des- 
pair, so if the opposed condition or passion, irritability or pee- 
vishness, belongs to the accelerated pulse, that, in similarly ex- 
treme cases, may amount to anger, or to a tendency to that fun- 
damental passion, easily excited by trivial causes; not seldom, 
difficult to restrain, even when no external cause is applied, or 
proceeding to causeless conduct, even in solitude, unaccountable 
to the patient himself. 

Now this mental derangement, be its mode what it may, is a 
symptom of unquestionable fever; and in the modification un- 
der review, where it equally exists, it may be the only symptom 
visible to a bad observer. Hence another common source of 
error; and thus is this modification of remittent, when slight, so 
often mistaken for hypochondriasis as it is, generally, for what 
is called a nervous disorder. Should there be undisputed fever, 
then is it nervous fever: and hence probably the origin of a term 
which has aided in misleading practitioners, and systematical 
writers too, so long. 

Though I shall have occasion to notice these particular men- 
tal disorders or symptoms again under the head of intermittent, 
I must still prolong these remarks here for a short space, chiefly 
because of the erroneous conclusions to which they lead; while 
I must also observe, as is also true respecting the whole, that 
while they are sometimes absent in severer cases, or, possibly, 
attract less notice, from the severity of more teasing or painful 
symptoms, so they are often very conspicuous in milder ones, 
possibly called into notice by the absence of greater evils, while 
equally tending to mislead the patient and practitioner. 

Despair and fear, analogous passions, are, rather than anger 
and its modes, the two great mental affections of all hypochon- 
driasis; and hence it is that fear chiefly, often attends the parox- 
ysm of this obscure remittent. This, however, is true of marsh 
fevers generally, whether remittent or intermittent, and under 
all the modes of these diseases. So remarkable indeed is this 
mental condition, fear, in the disorders of this nature, that in 
some parts of the Mediterranean where these fevers are ende- 
mic, the only name by which they are known to the common 
people, is Scanto; fear or fright. Nothing can express this cha- 
racter more strongly; while it is singularly justified, as 1 am 
well informed, by the extraordinary effects on the conduct and 



44 CHRONIC AND OBSCURE 

opinions of the patients which it produces. Anxiety is but a 
mode of fear; so that I need not refine on the display of these 
mental sufferings. This state is, as I have said, most often at- 
tached to the depressed pulse, though it also accompanies a par- 
tial delirium attending the reverse state; or the cold fit. And 
as the impressions of external objects, or occupation, counteracts 
these passions, so is it common for them to be conspicuous in 
the night, even when little troublesome in the day. Hence if 
these particular states should occur in the night, those passions 
acquire their full sway; the observation, as to the occurrence of 
a feverish fear and unreasonable anxiety at this period, being fa- 
miliar, when the cause has been overlooked or unsuspected. 
Moral writers have noticed it familiarly, as well as medical ones; 
and were I inclined to quote a passage to this purpose, I know 
not that I could select a better than from the letters of M. de 
Sevigne. 

In many cases, the morbid state of mind amounts to absolute, 
if transitory, delirium; while good observers, accustomed to 
watch the actions of their own minds, can ascertain that there is 
often an activity of thought, a hurry, or a confusion, which me- 
taphysicians know to be the approximating condition, but which, 
as is usual in all slight cases, can be removed by the presenting 
of other objects, or of subjects diverting the attention; by the 
mere act, for example, of introducing a light, or by conversa- 
tion, should any one be present. This is the delirium of a fe- 
brile paroxysm : there is fever present, from some cause: how 
many other causes may produce such fever, it is not my business 
here to say: it is sufficient that it is the produce of the remittent 
in question, while it is important to notice that if it is sometimes 
mistaken for nervous disease, as the phrase is, so is it attributed 
to dyspepsia, or to a presumed hectic fever, the supposed result 
of imperfect or disordered digestion. It will be for physicians 
to inquire whether this disease, real enough at times, has not 
also been imagined to exist when the real disorder has been the 
one under review. 

It is far from my intention to generalize so widely, and so 
unwarrantably I may add, from one cause, or so to give myself 
up to one theory, as to suppose that every case of transitory 
nocturnal delirium, or aberration of judgment, is the produce of 
remittent fever such as I now view it. Far from it. I do not 
suppose that our knowledge of the causes that may act on the 
brain is sufficiently advanced to decide on any thing, scarcely 
even to infer any thing, as to this subject, with a rational pro- 
bability. But the inquiry is an important one when the effects 
are often so serious; and it will surely be a justifiable question, 
whether among these cases, there may not have been some 
which were the produce of the febrile paroxysm of the modifi- 



REMITTENT, 45 

cation of fever in question, aided, as all those conditions of mind 
are, by the absence of objects fitted to divert the train of thought. 
Whatever be the causes, it is a fact well worth recording or re- 
collecting, that some of the most remarkable suicides have been 
committed on rising in the morning, and in a certain paroxysm 
of fever, which many persons, who have felt and checked that in- 
clination, have described as attended with confusion of thought, 
thirst, a tremor of the hands, and other unequivocal symptoms 
of fever. 

To quote noted instances of this nature would be abundantly 
easy, but it would be painful, and cannot be necessary; while 
perhaps, with them, we might safely rank a well-remembered 
murder, that of Mr. and Mrs. Bonar, where no previous de- 
sign, nor no purpose to be gained, seems to have existed. It is 
a subject, altogether, which might be discussed at great length; 
but I am scarcely justified here in pursuing it further: while, as 
a marked symptom in the disorder under review, it could not 
have been passed over. 

Yet let others reflect on a view of this suspected occasional 
cause of the highest moral misconduct, which must not be re- 
jected because it is new, and which I would attempt to illus- 
trate further, did I not think that my readers would be more 
likely to admit it if allowed to examine it for themselves, than 
if thus urged on them. If it be a cause, it cannot be unimpor- 
tant as to questions of medical jurisprudence, in modes that I 
need not suggest: while, as to suicides, the term febrile delirium 
should evidently be substituted for lunacy, affording an easy 
solution in the place of one which is, far too often, expedient 
rather than just. If it be true also, or indeed were it untrue, 
but could it be believed and also generally known, it might ope- 
rate as a salutary restraint on many whose delirium is not so 
engrossing as to deprive them of all reasoning power, and who 
in being thus convinced that their false views were the produce 
of bodily, not mental, disease, and that they would change with 
the hour and open better prospects, might acquire firmness to 
resist a temptation which is well known to be often very tran- 
sitory. 

To finish with the affections of mind belonging to this obscure 
remittent, I cannot omit its effects on the intellectual faculties; 
though as these are not a very universal possession, their condi- 
tion is not often brought under cognizance of the attendant prac- 
titioner, who ought also to be a person of intelleclual attainments 
and habits himself, before he could observe their operations in 
others. That they are variously affected by this disease, I have 
that assurance from observers and from observations, which ad- 
mits of no doubt; while it is most essential to remark, that among 
men whose intellectual faculties are in constant requisition, at all 



46 CHRONIC AND OBSCURE 

hours, and who are not under the influence of a morbid imagi- 
nation, or of selfishness as to their personal ease or inconvenience., 
such effects are sometimes the sole disease complained of. The 
physician who may be consulted on such subjects, and who may 
not have attended to this question, may perhaps learn to profit 
by the remark. It is a remark however which deserves a few 
more words; since surely there can be no physician, engaged 
among intellectual patients at least, who has not been assailed 
with complaints of this nature; though it is to be feared that they 
are often treated with a contempt which they do not merit. And 
he who will watch them, will find that they are often very re- 
gularly periodical; while a little exertion, or interest in the pa- 
tient, will also trace, in certain cases, the very febrile disease of 
which I am speaking: though I must not say that every such pe- 
riodical mental affection belongs to this remittent. And if such 
a character in this disorder has always appeared difficult of ex- 
planation, here is a solution for at least a certain proportion of 
cases; while, what is more important, that solution indicates the 
method of cure. And if, in a disease not much claiming medi- 
cal aid, such opportunity should not be afforded to physicians, 
or should they, from want of sufficient intimacy, or other ob- 
vious causes, not have the means of investigating it accurately, 
the patients themselves, with these hints, may learn to trace the 
real nature of the affection, by attending to the various concom- 
itant symptoms which are here pointed out in so many places, 
and to the causes whence the original disorder arose and through 
which it is renewed. 

And if I dare not here enlarge much on a subject which would 
carry me far into the history of the slighter mental derangements, 
I am still bound to observe, that some very remarkable cases of 
this nature, which had been attributed to various imaginary 
causes, and even to a tendency to mania, have proved to be no- 
thing more than these delirious conditions (if such I may call 
them) connected with a remittent fever of a slight character; 
while these cases have been most striking in men called on for 
much exertion: partly because that exertion prevented the sus- 
picion of fever, and partly perhaps because the mere mental la- 
bour itself aggravated the symptoms; calling them at least into 
more notice. Let those to whom cases of this nature may here- 
after present themselves, keep this at least in view; since 1 can- 
not help thinking that it will often be of much service to phy- 
sicians, and of still more to their patients: while if any one is in- 
clined to suspect this statement to be fanciful, let him investigate 
the mental conditions of the inhabitants of acknowledged dis- 
tricts subject to the chronic fevers of Malaria, in France and Ita- 
ly, and even in England, and convince himself that what I have 
here stated as a disease connected with this cause, is actually so 



REMITTENT. 47 

dependent upon it. How widely mischief, or even serious in- 
jury, has been inflicted on the patients in these cases, by mista- 
ken modes of cure, applied on wrong views of the cause, will 
appear in a more proper place hereafter, when the effects of re- 
medies as to good or evil in all these disorders, is examined. 

There are two states of mind in this case; and while they ge- 
nerally occur, both, within the diurnal period, they are also, 
when duly watched, found so accurately to accompany the states 
of the febrile paroxysm to which, even from theory, we should 
refer them, that we can scarcely entertain a doubt as to their de- 
pendence on a fever, and on a remittent fever; whether it shall 
be granted that I am right or not in referring that fever to the 
class of diseases under review. When however I say remittent 
fever, in this, as in any other case where these symptoms have 
been detailed, I must repeat one remark and make another: the 
first, namely, that the same results occur in habitual intermit- 
tent, and the second, that while there are double intermittents, 
so there are also double diurnal paroxysms in this remittent; in 
consequence of which, not only the mental symptoms, but all 
the effects, become complicated, so as to demand consideration, 
or exceptions, in reading these remarks; as they also often re- 
quire acute attention on the part of the physician who would 
make those cases his study. In fact, as I shall have future oc- 
casion to notice, the limits between this mild and chronic remit- 
tent and the intermittent of the same character, are so very in- 
definite, in every sense and as to every symptom, that it is only 
to change the terms, and nearly the same rules apply to both; 
while we cannot sometimes decide which of the two names we 
should give to the disease, and while they pass backwards and 
forwards into each other, or are interchanged in various modes. 

The conditions of the intellect then which I would here re- 
mark, are those of torpidity on the one hand and excitement on 
the other: the first consisting in an inability to think, sometimes 
attended by confusion of thought, and the other in an excessive 
flow or crowding of ideas, necessarily, in many cases, attended 
also with similar confusion, but from the reverse cause. I am 
much mistaken if both these states are not well known to many 
studious persons, and most of all to authors; the latter, which 
may be classed with the state of delirium, being not only friend- 
ly to rapidity of composition, but to the exercise of the imagi- 
nation, provided it be not in excess, while the former is hos- 
tile to every thing. 

It is for authors and studious men themselves, to investigate 
from how many causes they are subject to these two states of 
mind: my business here is merely to show how they are asso- 
ciated with a marked fever which possesses so many other de- 
cided symptoms, is so perfectly a remittent or an intermittent. 






48 CHRONIC AND OBSCURE 

or both in rotation, with a cause to be traced, and with a pro- 
gress not to be disputed, that no question can exist respecting 
its power and action in producing those mental conditions. 

In this marked disorder then, the state of torpidity or inabili- 
ty accompanies that condition which must be considered as the 
cold stage, or which is the commencement of the diurnal pa- 
roxysm; being noticed, of course, only when the attack com- 
mences in the day and in the hours of labour, and therefore of- 
ten passing without remark. And in every fever, this is the 
period of peculiar mental inability; the one observation con- 
firming the other. 

The period of excitement, or of increased, if of hurried men- 
tal power, on the other hand, is the hot fit, or that which is 
here its substitute; a period of partial delirium: and here also, 
that condition of mind which is useful in moderation, is illus- 
trated by the other, or by that excess which causes the imagi- 
nation to run wild. Reversely, if the opposed condition is also 
a state of the fever, it is that which, in a higher degree, be- 
comes coma, and in its extreme, apoplexy; yet it must be re- 
collected that inability to think may also be the result of exhaus- 
tion or fatigue during the interval, though this is, metaphysical- 
ly, a very different species of inability from that which depends 
on the torpor of the nervous system. These conditions, it is 
plain, are the torpidity and the excitement of the nervous sys- 
tem, which form two such hackneyed terms in physic: yet 
while physicians have been accustomed to use them as causes, it 
is plain that they are but effects: and that, used in the former 
sense, as they have been, they but lead us round in a circle, ex- 
plaining nothing. This is the loose and useless language of phy- 
sic, by which readers as inattentive as the writers are misled: 
and he who chooses to read what Cullen has written on mania 
and on sleep, will easily convince himself that I have not stated 
what is not true; since he will at once perceive that the whole of 
that, and much more, is a specimen of this encycloidal — rea- 
soning, I ought not to call it. A better logician would have 
seen that he was abusing words and deceiving himself. 

But I must cut short a subject that would admit of a volume, 
in the usual way of discussing such questions, and proceed to 
notice the remaining bodily symptoms of this particular fever. 

In the very slightest cases, headach may not be present, but 
it is far more common in women than in men. Very frequent- 
ly, debility, with headach, constitutes, with that sex, the sole, 
or the sole obvious disease: and with these symptoms, alone, or 
apparently so, the disorder will sometimes run a course of six 
weeks, and with such severity as to confine the patient to bed. 
In this case, the act of confinement constitutes it a nervous fe- 
ver, in the conception of those to whom a bed forms an essen- 






REMITTENT. 49 

tial part of a disease. The man who will not, from temper, or 
disdain, hold to his bed, is not supposed to have a nervous fe- 
ver; while respecting the woman in the same disease, of the 
same severity, there is no doubt. To what judgment the male 
patient may in this case be subjected, depends on his rank, his 
pursuits, his opulence, his love of physic, and much more than 
it is needful to discuss here: but this is the case where the un- 
lucky soldier is found guilty of fraud, as the persevering spirit 
which will not surrender, and which adds, to the natural debili- 
ty of the disease, the exhaustion produced by his efforts in spite 
of it, is the object of another kind of censure to those whose 
minimum of good sense and good nature cannot distinguish be- 
tween excess of fatigue, or positive exhaustion and loss of tern- 
per. 

Here also, and whenever the disease becomes somewhat bet- 
ter marked, we find the other common symptoms of fever; fits 
of restlessness or lassitude, with occasional pain in the limbs, 
and not uncommonly in' the feet and ankles; and as these are 
noted or complained of, the disease is commonly judged to be a 
fever or not. It is, in short, in all its points, when slight, one 
of those disorders more judged of by the patient's courage or 
debility of mind than by its own intrinsic symptoms: an excel- 
lent rule of judgment, assuredly, and one that is very likely to 
throw light on diseases. 

With respect to sleep in these varieties, it is regulated by all 
the laws that hold in the more perfect and marked remittent fe- 
vers: but as the appearances are generally neglected or mistaken, 
while they also lead to wrong practice, and as the inconveniences 
to the patients are not small, they deserve an inquiry before I 
terminate this account of the disorder. 

I must first remind the reader, that a comatose state, or a* 
drowsiness, is a very common symptom in this disease; occur- 
ring also in that intermittent, between which and the disorder 
that I am now describing, the distinction is so difficult to make. 
In fact, as I have more than once said, it is little more than a 
dispute about terms; as the disorders themselves are essentially 
the same, and as the same patient, if suffering chronically, will 
experience both, in different seasons and circumstances. 

This attack of drowsiness, when it exists, generally com- 
mences with the paroxysm, and is often the first warning of it; 
while it is often so sudden, that a patient will fall asleep even in 
the act of conversation, or may find the greatest difficulty and 
pain in preventing it. It offers an exact analogy to the more 
perfect apoplectic state, which is so often the first attack of the 
fevers of Italy. Sometimes it is temporary, terminating in half 
an hour, a quarter, or even within one minute; but, while irre-r 
sistible, those who have experienced it, describe it as more re^ 

7 



50 CHR0NI€ AND OBSCURE 

sem-bling what they should conceive to be the effect of a narco 
tic poison, than natural sleep. In other modes it lasts for many- 
hours; the patient being unable to rouse himself into a properly 
waking or active state, while, at the same time, he cannot pro- 
cure even a minute's real sleep; the bare attempt defeating his 
object. All those who have suffered this symptom from the 
chronic fevers of Italy, describe it as extremely distressing, and 
as one of the most vexatious parts of their disease; and I need 
scarcely point out to medical readers, that while it may rank 
under the Quotidiana soporosa of Sauvages, they may find abun- 
dant mention of it in medical writers, at least in cases of severe 
or marked fever, though it is so often overlooked or mistaken 
in our own country. Even in foreign writers, I must however 
remark, I can find no decided view of this disorder as appear- 
ing in a fever of this slight character, or in one, of which, while 
the proper fever is easily overlooked, this constitutes the only 
very marked symptom. It seems to me, on the contrary, that 
it is generally confounded with a simple and primary disease, if 
indeed there be such a disease which is truly independent. 

The error to which 1 allude is that of calling it by the vague 
term Lethargy, and it is often an error of a very serious nature; 
since, among vulgar or unobserving practitioners, it leads to the 
practice of bleeding or cupping; remedies which, in general, 
materially aggravate the chronic disorders of this nature, some- 
times even inducing real palsy: or, as is also not unusual, it is 
judged a reason for courses of purging and of abstinence, simi- 
larly injurious, if less actively mischievous. There can hardly 
be a physician who has not met with instances of this nature; 
while, not occurring necessarily in corpulent or aged patients, 
and the fact indeed being often quite the reverse, it might at 
least be conjectured that it did not arise from that cause, excess 
or misdirection of the circulation in the brain, to which such 
diseases are vulgarly attributed. 

Now, it may happen, as with respect to debility, formerly 
mentioned, that this drowsiness will be the only conspicuous 
symptom of the chronic fever in question; and it is most fre- 
quently so in those who are not of a complaining character, not 
given to watch their morbid sensations, or who are under the 
necessity, or in the habit of exertion. And if, in such instances, 
it is thus the only conspicuous or obvious disorder, it is so be- 
cause it forcibly commands that attention, from its interference 
with the actions or occupations of the patients, which the other 
symptoms, if present, do not. It will rarely however happen, 
but that a watchful physician, accustomed to observe and reason, 
he who is habituated to the analogies and generalizations of 
philosophy and is not the mere slave of terms, will trace other 
symptoms, sufficient to convince him of the real nature of this 



REMITTENT. 51 

imaginary lethargy. He will, or he ought to observe its peri- 
odical attacks, and he will also generally find that other peri- 
odical changes attend it: he will trace a periodical change in the 
pulse; and, what is perhaps as decisive as any symptom, though 
it is that which is especially neglected, he will be able to disco- 
ver the commencement of a paroxysm in the altered physiog- 
nomy of the patient; in a shrinking of the features, especially 
of the nose, and in a corresponding paleness of the skin, simi- 
lar to that which commences the cold fit of an intermittent. 
Whenever this disease is found in a patient who has been habi- 
tually a sufferer from decided remittent or ague, that alone ought 
to prevent it from being mistaken. 

I could easily fill pages with cases of this nature, as of others, 
illustrating every modification of this disease which I have de- 
scribed; but while this would be to occupy room, it would add 
nothing to the evidence which the generalization presents. In 
all instances, the evidence afforded by cases can be no greater 
than that which is deduced from them by the recorder's own 
generalization: while reversely, in both, in the particular as in 
the general, incapacity for observation, prejudice, or mala fides 
will equally vitiate the testimony. 

But I cannot pass from this symptom without briefly point- 
ing out, though it rather belongs to the cure of these diseases, 
the mode in which erroneous practice often confirms the false 
conclusion, that such a disease is that which medical writers 
have called lethargy, and associated with the purely apoplectic 
and paralytic disorders. I shall hereafter show how, in all 
these diseases, the practice of bleeding leads to paralytic and 
permanent affections: and while this is also one of the proposed 
remedies for lethargy, it is easy to see that when the sequel is 
palsy, the original error will be confirmed; when the very prac- 
tice itself has been the cause of the evil which it was intended 
to prevent. Of such events, I have ^en cases enough to con- 
vince me that they are not of uncommon occurrence. 

To proceed to the sb*« oi natural sleep in this disease. It is 
common for it to be irregular or disturbed; variable or unnatu- 
ral as to the period, or interrupted inconveniently. In these 
cases, it will be found that its irregularities depend on the pe- 
riod and proceeding of the diurnal paroxysm, though the ap- 
pearances are various and often intricate. Hence, it is protract- 
ed beyond the usual period, or the patient is unable to sleep till 
a late hour of the morning, or else is awaked at some hour of 
the night with his sleep unfinished, being under the necessity of 
repeating it after the interval of watching has passed away. In 
this latter case, that confusion or hurry of thought already de- 
scribed, amounting nearly to delirium at times, is not uncom- 
mon: and it is also remarkable that the hour of morbid awaking; 



02 CHROMIC AND OBSCURE 

will, through long periods, return with the utmost punctuality, 
This indicates the connexion with the paroxysm of remittent 
here noticed; while the proof is completed by this fact, that 
while, in the chronic cases of remittent and intermittent, the 
hour of the attack will remain unchanged, even for a long 
course of years, or for life, so does the hour of awaking under 
this modified disease, remain equally constant. One case, which 
I shall briefly state, will illustrate sufficiently what I could elu- 
cidate by many more. 

In this, the patient had, for thirty years, been subject to near- 
ly all the diseases in rotation which I here rank under those of 
Malaria, namely, to remittent, to intermittent, and to almost 
every known variety of Neuralgia; having apparently acquired 
the incurable habit of these disorders at an early period of life. 
In several long intervals among those more marked ailments, 
the same person had also been affected, for long periods, with 
simple coma or drowsiness, and further with nocturnal awaking 
in the state of partial delirium just described: and it was his 
invariable remark, that the hour of awaking in this manner, was 
always precisely the same as that which marked the paroxysms 
of the intermittent and those of the Neuralgia, indicating their 
joint dependence on one cause and one habit; while that hour 
scarcely ever had varied by many minutes during the whole of 
his life of disease. 

I am not about to deny that similar symptoms occur, possi- 
bly from mere habit, and that they happen in many febrile and 
nervous diseases where the existence of remittent cannot be sus- 
pected. But as they are portions of this disorder also, it was 
necessary to notice them; particularly as they seem to have met 
w T ith very little attention as such, and as a discriminating know- 
ledge of the cause is important in determining on the mode of 
cure. 

In any cases of this nature there is a remark which I feel 
bound to make, be the cause or tK^ disturbed sleep what it may; 
as it is a fact on which the comfort of patients of this class ma- 
terially depends, and as the popular opinion^ in this case are of- 
ten rendered very oppressive to them, implying also, as they do, 
a proverbial piece of vulgar morality. It relates to early rising, 
presumed to be peculiarly salutary; as the contrary practice is 
even held to be immoral. Thus is the unfortunate invalid, who, 
from whatever cause, is subject to a late period of sleep, or to 
interrupted sleep, condemned to square his life and risings by 
the rule of those to whom ill health is unknown, as among them, 
it is doubted or despised. And thus also do conscientious or 
timid or superstitious persons impose this law on themselves, 
with consequences which all those who have submitted to it 
know but too well Of these consequences, the chief are, ina- 



feEMITTENT. 53 

hility for exertion generally, and for thinking in particular, du- 
ring the remainder of the day; when the cure, or prevention, 
would have been found in following the obvious dictates of the 
feelings, and in sleeping through that period in which exertion 
of any kind is injurious, or while the peculiar febrile state is 
present. 

This would be the real economy of time, if that be the mo- 
tive; and it is, no less, economy of health, as it is avoidance of 
suffering. But not until those reasoning faculties which are 
thought to distinguish man from the inferior animals shall real- 
ly become the general property of men, will it serve any end 
to say that he is the early riser whom a sound constitution has 
destined to a long life, and that it is not because he has risen ear- 
ly that he sees the borders of fourscore? A still harder task 
is his, who, in addition, has to encounter one of the proverbs 
which serve the purpose of evidence and philosophy equally, 
to the vulgar, great and petty; still more, who would oppose 
that superstition which conceives itself to be religion, and that 
latent, but ever-active asceticism which imagines the voluntary 
infliction of pain a merit. 

It is to be expected that the prima? vise should be deranged 
in this disease, as I have already remarked; but while I did not 
choose to dwell on what seems always to possess a peculiar at- 
traction for the multitude of writers and practitioners, I must 
observe that where the visceral glands are affected, as is very 
usual in cases of a chronic or repeated nature, such events are 
peculiarly to be expected; while, on such a subject, the reader 
may easily refer to numerous treatises respecting those glandu- 
lar diseases; as I do not intend to include any account of them 
in this essay, for the reasons which I assigned, when speaking 
of dropsy formerly. 

Whether connected with that state of things or not, I must 
however, offer some remarks on what is called dyspepsia; a Pro- 
tean disorder, as it is commonly apprehended, and one which 
is rarely absent, in some form, from the chronic remittent and 
intermittent. It is not here my business to enter on the consi- 
deration of dyspepsia as a disease, nor on that of all its possible 
causes: it is sufficient if it is here a symptom and a produce of 
the disorder under review; while, being so, the fact is import- 
ant as connected with our practice in it. 

That it is actually so, every man's observation may satisfy 
him: that it must be so, if the great glands are affected, every 
one would anticipate; so that this consequence requires no fur- 
ther illustration. But it is important to show how it arises in 
fthe simpler fever, where those diseases do not exist; because 
we are thus led to a method of cure, or rather, of prevention. 
In every fever, and in the remittent of course, the stomach 



54 CHRONIC AND OBSCURE 

is in a disordered state; while where the interval is perfect, it 
recovers its powers, totally, or partially, as it may happen, 
during the cessation of the paroxysm. I ought also however to 
remark, to prevent cavil or error, that in all these fevers, whe- 
ther severe or slight, the affection of the stomach is very va- 
rious; as it appears, in some cases, to be the chief organ suffer- 
ing while in others it may almost escape, and even where there 
are no differences in the severity of the fever to justify these 
different conditions. Like much more, it is, probably, rather 
a local disease attached to the primary one, by means of colla- 
teral and connected causes unknown to us, than an inherent es- 
sential symptom or portion of the total morbid change. But 
since I have, in another place, given the remarks of French 
writers on the direct production of dyspepsia from Malaria, 
while I have, in noticing the theory of remittent, pointed out 
the inflammatory state of the stomach, and while I need not, to 
medical readers, describe those severe affections of this organ 
which take place in the remittents of the tropical climates, it is 
here unnecessary to dwell on facts or illustrations which are 
either independent, or very materially so, of the particular mo- 
difications of this disorder under review. 

The point now to be remarked is this, that while, in the de- 
cided remittent fever, the digestive powers may recover during 
the interval, yielding under the paroxysm, so a similar effect 
often takes place in the chronic and gentle remittent; or in the 
disease under consideration. And in the severer disease, if it is 
not attended to as it ought to be, all physicians of any observa- 
tion must know, that if food is to be. given, the interval, and 
even its first moment, ought to be selected; that the digestion 
may, if possible, be completed before the return of the paroxysm: 
and that to allow it during that stage, is not merely to defeat its 
object, but to increase the fever, and often to lose the remission, 
or render the disease continuous. 

The case is precisely similar in the chronic or mild disease 
under review: but the obvious result in this case, is indigestion, 
with its usual train of symptoms: as the ordinary conclusion 
also, by the physician who does not know the disease that is 
present, is, that the patient is merely labouring under dys- 
pepsia. 

Thus does remittent in this form, to vulgar eyes, put on the 
mere character of dyspepsia; since, as in the other cases, the 
other symptoms may be neglected, and from the same causes; 
which I need not again repeat. Nor need I repeat how the di- 
agnosis, as physicians term it, may be formed in this case; though 
it is important to remark that the cure, at least to a certain ex- 
tent, will be found, as I formerly hinted, in merely varying the 
hour of eating: selecting, of course, the interval or the diurnal 



REMITTENT. 55 

period of health, be that what it may. The patient's own feel- 
ings or appetite in this case, will often be a sufficient guide, 
where better are wanting: while it is plain that in such instances, 
the established habits of society in regard to eating, must often 
be broken through. 

If I could prove that this is a correct view of a certain pro- 
portion of the cases of imagined dyspepsia, by means of specific 
histories of such, this is another of the instances also in which 
such evidences would be superfluous, and for the same reasons. 
Let physicians watch their own cases of this disease with this 
new light, and they will scarcely fail to find evidences of their 
own which will be much more satisfactory. And they will re- 
collect also, when they reflect on their practice, how 9ften they 
have found dyspepsia periodical under diurnal returns of various 
kinds, how often periodical and dependent on seasons, how often 
they have seen it cured by merely altering the hours of eating, 
how often by bark, or by arsenic, or by the other tonics that 
cure the remittent and intermittent diseases; and how often by 
change of air, as also by mental affections, or causes operating 
on the imagination, such, among others, as the change of phy- 
sicians; all of them remedies for the intermitting diseases in 
question. 

I dare not enlarge on this view, important as it appears to 
me; since were I to pursue the illustration of every disease 
which occurs as a symptom in the anomalous or obscure fevers 
arising from Malaria, I should write a universal treatise of 
physic. Yet amid all the treatises, almost numberless, which 
have been written on dyspepsia, this is a mode of contemplating 
it which I have not found: while I need only say that any one 
who will reflect on those circumstances appertaining to it which 
I have just suggested, will see that they can all be explained by 
the theory here proposed, while there are few that admit so 
easy a one, and some that will scarcely admit any other. Of 
the very numerous real causes of this common disease, I can- 
not pretend to give even a catalogue, as that would be to trans- 
gress my plan; nor could I therefore enter upon any compara- 
tive view of the predominance of these several causes, or at- 
tempt to suggest what place the one here proposed may deserve 
among them. As far however as utility is concerned, it will 
be sufficient if physicians shall become aware that there is such 
a cause; while the method of ascertaining its presence will 
scarcely now be difficult to a careful practitioner. 

I must now notice the occurrence of hysteria as one of the 
symptoms occasionally attending this fever; because, though ra- 
ther an incident than a portion of the disease, it is important 
that it should be known to practitioners to arise from this cause, 
more generally than it appears to be, 



36 CHRONIC AND OBSCURE 

In the better marked remittent fever of this mild and tedious 
character, it is not an unusual symptom; and if, as is probable, 
it is most common in women, it occurs in both sexes. That, 
with such a symptom, the terms nervous fever, and fever on 
the spirits, should appear well applied, is not very surprising: 
but as humanity or compassion to the sick, from those who are 
well, is not one of the most prevailing of virtues, and as any 
disease usually associated with debility of mind in the common 
estimation, is a general object of contempt or censure, it is not 
uncommon for the who)e disease, even in this case, to be attri- 
buted to feebleness of mind, a nervous constitution, or any other 
cause which may justify that contempt with which the diseases 
called nervous are so commonly treated. 

In the severer, or more strongly characterized remittent, or 
low fever, (to adopt this popular term,) where the general fe- 
brile symptoms are sufficiently marked to admit of no dispute,, 
while there are generally present most of the ordinary symp- 
toms called nervous, the occurrence of the hysterical paroxysms, 
which is rarely more than a fit of crying, is commonly as regular- 
ly periodical as any other portion of the disease. I am not how- 
ever quite satisfied respecting the part of the febrile paroxysm to 
which it belongs; but have generally observed that it attends 
the subsidence of the pulse, and therefore, that it occurs to- 
wards the end of what would be the hot fit, or at the termina- 
tion of the excitement, were that stage well marked, which it 
very often is not. 

Now, on the other hand, it often happens, that either the fe- 
ver has so far subsided that no marked symptoms of it remain, 
or that it has originally been of so slender a character as to at- 
tract little notice, as fever; particularly should the patient be of 
a courageous disposition, and determined to affect health as far 
as possible: while there are also cases in which it really is ex- 
tremely slight. Yet even in those states, the game paroxysm 
of hysterical weeping or feeling will occur; while I have ob- 
served, in some cases, that not only it is the only part of the 
disease which the patient's efforts cannot resist, but that it is of- 
ten rendered additionally certain and conspicuous if he has made 
efforts to conceal the febrile paroxysm, or to exert himself un- 
der it. A long-continued attempt at exertion, or at conceal- 
ment, which is exertion, is, in such cases, generally followed by 
a hysterical affection unusually severe. 

In females, if other nervous symptoms are present, and if 
there are especially that despondency and irritability which I 
have shown to belong to this fever, and if, further, the attend- 
ants are prejudiced and the physician ignorant or careless, such 
cases are sometimes considered as purely nervous, and conse- 
quently, very commonly maltreated. Whether they may be 



REMITTENT. 57 

•common cases ur nut, I must leave to the observations of others; 
as respecting these, my own ujjpuitunitlco have not been ex- 
ceedingly numerous, though far more than sufficient to establish 
the fact; while I shail also leave it to the consideration of others, 
to judge hereafter, when I shall take an opportunity of referring 
to authors, whether the cases of periodical hysteria thus recorded, 
do not belong to this disease, far more extensively than in those 
instances which such systematic or casual writers have quoted, 
and whence Sauvages has erected his variety of tertiana hyste- 
rica. As far as I can perceive, such hysteria has been noticed 
under this head, only where there was a proper and perfect in- 
termittent ; whereas, according to this view, it may be the only 
very visible disease. 

Thus I have enumerated the leading and conspicuous symp- 
toms of this modification, or of these modifications or varieties, 
of remittent fever, as far as they may be considered general; re- 
serving those which seem more properly of a local nature to 
another division of this subject: though with regard to the sto- 
mach as affected by dyspepsia, that might also have found its 
place hereafter, since I must reserve that affection of this organ 
which consists in vomiting, to that future place. Unfortunate- 
ly, such is the character of the stomach and its diseases, that the 
latter may often be considered equally in either light. 

I have now therefore only further to remark, that it is one 
of the effects of this remittent, particularly when chronic or ha- 
bitual, to produce those general derangements of the entire 
health which it would be tedious and equally useless to enume- 
rate, as they are familiar to every one; while with that, the 
temper, and even the moral character, as it may be considered, 
become also permanently or habitually injured. This, however, 
I shall have occasion more particularly to notice under the head 
of intermittent; and I shall therefore terminate this part of the 
subject with pointing out one effect, in females, which especially 
demands notice; because it is far too common to overlook its 
causes, not only in this case, but in many others, and to treat as 
an original disease, that which is only a consequence of others. 

I allude here to menstrual errors, which may be of any na- 
ture, while the more common are dysmenorrhea and amenorrhea; 
the latter in particular being frequently attended by a chlorosis, 
which has often been mistaken for an original disease, as I 
have witnessed: most especially, of course, in those cases where 
the accompanying fever was slight, while the deception is, 
further, easily maintained by the existence of headachs, equal- 
ly belonging to the proper fever, and not to this local and se- 
condary disorder. On those derangements I need make no fur- 
ther remark, than to request practitioners to inquire sedulously 
into their causes, and more especially respecting the one under 

s 



38 CHRONIC AND OBSCURE 

review, (since this is the only part of that subject which ia un- 
der discussion,) because, un mis, me cure must be founded: and 
further to reflect, that they are, in themselves, much more com- 
monly the results of some derangement of the health, than the 
sources of that ill health by which they are accompanied, and 
which is generally attributed to them. It is a subject, however, 
which will necessarily be noticed again when speaking of the 
anomalous intermittents: while this unavoidable necessity of al- 
most repeating the same statements in two different places, be- 
cause of the division of marsh fevers into remittent and inter- 
mittent, together with other consequent disordered arrange- 
ment which I have been unable to avoid, inclines me often to 
wish that I dared to have departed from the common usage of 
physic on this point, and treated, as one whole, things which 
are not essentially different. 

If I have now sufficiently described this modification of re- 
mittent fever, as I consider it to be, through its obscurer modes 
and symptoms, and if I have also given such distinctive charac- 
ters as shall enable any one, with a moderate degree of atten- 
tion, to recognise it, I have hitherto spoken of it as a definite 
disease, occupying the usual periods of other and more severe 
remittents. This was necessary for the sake of distinctness, 
and that it might the more easily be compared with the ordinary 
and acknowledged remitting fever: but it is a description that 
will seldom apply in practice, as far as the duration of the dis- 
ease is concerned; and, on this point, I must now proceed to of- 
fer some remarks. 

Let me also here premise one observation, which, though al- 
ready made, requires to be stated more distinctly and forcibly, 
This disease, in actual practice, is commonly of long duration, 
as I shall soon show; while it frequently follows a severe attack 
of decided remittent, or an equally distinct one of quotidian or 
double tertian intermittent. It happens also that, according to 
season, or from the nature of the exciting cause of a fresh re- 
lapse, or from other circumstances, possibly not very apparent 
at present, it puts on rather the appearance of an intermitting 
than a remitting disease: the intervals, or intermissions, being 
perfect, perhaps long; while, further, there may be a distinct 
cold stage, however short, at the renewal of each paroxysm, 
Thus might it equally have been classed under the head of chronic 
intermittent with the quotidian type; though had I treated of 
it there, they who may now know it, or hereafter remark it, as 
a remitting disease without cold stages, might equally complain 
that I had misplaced it. There was but a choice; and I have 
placed it in the division to which I have found it most frequent- 
ly conform: while it is plain that the dispute, should it arise, 
is not worth entertaining, inasmuch as the whole is but onedis- 



KEMITTENT. 5$ 

ease under different modifications. It is, in short, the chronic 
febrile state of fever or fevers, which attend the unfortunate peo- 
ple who reside in the pestilential countries described in the es- 
say on Malaria: putting on an endless variety of appearances, 
from which I have attempted to condense, as far as lay in my 
power, a general description adapted to the majority of cases, 
or at least capable of serving as a point of reference for disor- 
ders which differ in almost every individual. It is, in reality, 
the chronic marsh fever; approaching, on one hand, to the acute 
and regular disease, and, on the other, to that undefined condi- 
tion of the same nature which is so often called, simply, ill- 
health: while, as to type, it maintains the same gradation of cha- 
racter; being continuous, in a limited sense, or remittent, or in- 
termittent, just as are the severe marsh fevers to which it is affi- 
liated. I am utterly indifferent where it is ranked, provided it 
he understood, for the sake of those who are its victims. 

But if I here expose myself to criticism by professing my ina- 
bility to decide whether this disease should be ranked with 
quotidian or double tertian, or else with remittent fever, I shall 
at least coincide with those who do not admit the existence of 
quotidian; while I am but in the same condition as those who 
invented the term hemitritsea to get rid of this difficulty. Sy- 
denham, Strack, many more, even including Celsus long since, 
seem to have felt similarly on the subject, though their remarks 
apply to an acute and severe, and not to a chronic or slender 
disease. But I have already said that these are often distinc- 
tions without differences; and since remittent and intermittent 
are virtually the same disorder,, we can only smile at the verbal 
refinements of those who, unwilling to abandon the term inter- 
mittent, say that its accessions may be protracted and confound- 
ed, and that it can thus become, deceptively, even continuous. 
Let us not split the hairs of logic on these subjects, now that we 
have shaken off the weight of the schoolmen in so many other 
matters. 

As I observed just now, the disorder in question is a frequent 
termination of a severe remittent, or of what is called a nervous 
fever; as it also is the sequel of a marked quotidian, under 
which I here include the double tertian. Such a remittent may 
terminate in a curable intermittent, or in the chronic one so dif- 
ficult of cure; but it will also subside into this particular disease, 
a copy of the original as it may be termed, but on a reduced 
scale. While the severe intermittent also, of whatever type, 
may terminate in a chronic one of the same character, the quo- 
tidian may similarly become chronic; continuing well marked, or 
else, by losing its cold fits and acquiring less decided intervals, 
ending in this chronic and mild remittent, so difficult of cure, 
and perhaps, of all the termination of this disease, the most die- 






60 CHRONIC AND OBSCURE 

tressing, from the almost uninterrupted state of disorder, both is 
the bodily and mental faculties, which it maintains. 

In such cases as this, and when the patients history can be 
traced, as it almost always may, with care, it is highly discre- 
ditable for any physician to mistake it for any of those diseases; 
bearing the corresponding collateral symptoms already described, 
which resemble it in those particulars: or, as is the fact, to mis- 
take the prominent symptom for the real disease, negligent of 
its cause and origin. Yet is this a daily error; as he who has 
watched medical practice will soon discover, or as he who has 
trod the routine of names will ev r en discover in his own prac- 
tice, if he has only talent to observe, when the right path is 
pointed out to him, and but candour enough to acknowledge his 
errors to himself. There is somewhat more of excuse when, 
from the beginning, the character of the disease has been mild; 
though even here, no one who can commit the error, deserves 
the name of a physician; if, to be a physician, is to be the 
philosopher which it was once supposed. He whose very sci- 
ence is the most obscure under the guidance of analogy, and 
whose knowledge, therefore, without an eye for analogies, is 
nothing, must be satisfied that he is but a practising artist, a 
man of receipts and names, if, under analogies so simple and ob- 
vious, he is unable to perceive what are the facts before him, 
and what their connexions and causes. 

Let me still point out one or two of the most common modes 
under which this disorder appears; or rather, some of the most 
ordinary misinterpretations to which it is subjected; since thus, 
perhaps, shall I best explain to others the views here taken of 
the diseases which they see and do not look at in the same light. 
It is in vain to describe any thing, unless we can bring it before 
the eyes of others by placing ourselves in the same position as 
they may be; and, with some more, the following are perhaps 
the most common appearances and conclusions among those 
whom it would be unjust to censure for not studying a science, 
when all which they profess to do is to practise an art; or, as 
a harsher criticism has often said, to conduct a trade. 

It is remarked, that after a severe fever, certain patients be- 
come " nervous and ailing," as it is termed, for a long pe- 
riod; and the vulgar opinion then is, that the constitution has 
" received a shock," or that the brain or the nervous system 
has been injured, or any other convenient reason of words. It 
is also remarked, that certain persons are very subject to slight 
fevers, that any little irregularity produces a fever, and so on; 
while of others yet, suffering less from this cause, it is merely 
concluded that they have bad constitutions, or ill health, or are 
nervous subjects, or much more than I need not be at the trou- 
ble of repeating. 



REMITTENT. 61 

Now, in the case where the " nervous fever," as it is called, 
has preceded, the imagined injury to the constitution is merely 
the relapse, or series of relapses, to which remittent is subject; 
or it is the mild disease already noticed, in a chronic or habitual 
form. The debility, the affections of the mind, the febrile 
symptoms, the nervous ones, all this and more, are the symp- 
toms of the fever itself, and nothing else; and assuredly did 
they depend ona " constitutional" cause, or were they the ef- 
fects of organic disease, the constitution might well be supposed 
injured. It is doubtless injured, and materially so, should the 
visceral glands be diseased, as does sometimes happen in these 
cases; but all the appearances of disorder in question may exist 
without that; while these disorders, whatever other evil they 
may produce, can scarcely be the causes of what may equally 
exist without them, and are assuredly not the exclusive ones, 
Thus also, possibly, may the nervous system, that is, the ana- 
tomical structure, or the functions of the brain and nerves, be 
permanently injured; though, as we have at present no know- 
ledge of the nature of such injury from anatomy or physiology, 
we cannot reason respecting it; while we further know, that 
the mere disease in question, while in action, will produce, tem- 
porarily, the effects that might be attributed to a permanent de- 
rangement of the nervous system or its functions. 

The facility of suffering from fevers, repeatedly, and from 
slight causes, or a habit of "taking fevers," will be found to 
be nothing more than the chronic disease in question. It may 
be so acquired ab initio; or, every fever, from the commence- 
ment, may have been a slight one, while the disease does not 
become the less chronic or habitual: but a careful examination 
will very often discover that the original attack has been a well- 
marked one, or that the mild fevers are the repetitions of a se- 
verer original disease. The case is the same as to constitution- 
al bad health, debility, dyspepsia, nervous disorders, or what 
not, generally referable, with care to some previous fever; while, 
in almost all these cases, (presuming of course that the causes 
are those here under review*) a watchful eye will discover the 
periodical character, or the other diagnostic symptoms, past or 
present, which have already been pointed out. 

And further, in those disorders, an examination of the pa- 
tient's present or former residence, or of the places which he 
has frequented or visited, will often also enable the physician to 
trace the origin of such affections to Malaria; confirming what the 
symptoms may indicate, or, sometimes, even proving what their 
obscurity or that of the patient's narrative may have left in 
doubt. It is very often with this narrative that a physician will 
have chiefly to contend; so deficient is the multitude in obser- 
vation, and so incapable of even explaining that which, to those 



62 CHRONIC AND OBSCURE 

who do not reflect on the ignorance and inaccuracy of mankind 
in general, would appear abundantly easy. And if in attempt- 
ing to give the natural history of Malaria, I have so often in- 
culcated the necessity of carefully studying the obscurer sources 
whence it may arise, so often maintained that this knowledge 
formed an essential portion of every practitioner's acquirements, 
here, among many more, is one of the cases where a perfect 
knowledge and a discerning eye as to this subject, will become 
an important auxiliary in the formation of a diagnosis, as phy- 
sicians term it. 

One remark more on popular errors respecting this disease, 
will be useful, before proceeding further in the account of it. 
It is a very common observation, that persons who had suffered 
much from ill health, in youth, or at a certain period of life, re- 
cover, and become stronger and healthier than even before. I 
do not here pretend to enumerate the various disorders under 
which such a state of things may occur; but I have succeeded, 
in many cases of this nature, in tracing the cause to a chronic 
fever of this character, persecuting the patient during the ear- 
lier years of life, and often, for an extensive period; as happens 
in chronic tertian and quartan: diseases, like this one, which, in 
after life, disappear, or are cured, by remedies unpereeived by 
us, or by revolutions in the constitution of the subject. 

And this particular fact, the subsidence or disappearance of 
marsh fever at a certain age, whether merely chronic or inter- 
mixed with acute attacks, is one of the circumstances remarked 
of all the insalubrious parts of France and Italy: where the pe- 
riod from thirty-five to fifty, as I observed in the essay on Ma- 
laria, is the period of trial, and where, if this is once passed, 
the individual often attains old age. And for the sake of those 
who prefer facts from our own country, it will be found that the 
same rule holds in Hampshire, and in the other districts subject 
to the fevers of Malaria, wherever these become chronic, or at- 
tend the whole of life, as they do in the countries just, named. 
These are cases without dispute, or which at least ought not to 
be disputed; because the connexion is apparent and the causes 
obvious: in those to which I allude, the causes are the same, 
and so is the disease: but these are the instances in which both 
the causes and the nature of the disease have been overlooked 
or mistaken, from the general inattention and ignorance respect- 
ing this whole subject, so often here pointed out. 

Reversely, let me offer an analogous remark on what has been 
called the climacteric disease; and if I should here appear to be 
infringing on the rights of Halford, as I must seem already to 
have done on those of Haygarth, by offering an explanation of 
his cases; I must not be understood to say that the cases of dis- 
ease under this term, which he has noticed in the same transac- 






REMITTENT, 63 

tions, were themselves instances of chronic remittent or inter- 
mittent, but that I have seen patients whose ages and disorders 
corresponded exactly to those which he has described, that these 
had been considered the climacteric disease, or, as I have else- 
where noticed, a " breaking up of the constitution," and that 
they were proved to be the fever in question, misapprehended, 
and, commonly, long, also, overlooked. Other physicians may 
consider this subject, and decide whether they have not, some- 
times at least, followed Halford in this opinion, and whether 
also, they may not have sometimes deceived themselves. 

Supposing this disorder, which I may perhaps safely call the 
chronic remittent to have been once established, from whatever 
original cause, its duration and character are, both, various; so 
various, that to describe them all, or to adduce cases for the pur- 
pose of illustrating them, would prove insufferably tedious. To 
notice some of the more ordinary and prominent characters of 
such varieties, will, I hope, suffice for forming a ground of judg- 
ment respecting the existence of the disorder; and the rest must 
be trusted to the discernment of practitioners in applying these 
general principles. 

Though it does happen that this disease, whether as a. marked 
fever or a merely inconvenient and almost undefinable feverish 
state, will appear to endure for many months, or even years, it 
is more usual for it to consist in a series of distinct attacks, or 
of relapses, with intervals of health, or of something like 
health; since, when the intervals in particular are short, the pa- 
tient is seldom restored to his proper vigour, and is seldom also 
without some inconveniences. This I already remarked of the 
better characterized " nervous fever" or chronic remittent; 
and it is equally applicable to the most slender or scarcely dis- 
cernible affections of the same nature. But the state of inter- 
val between any two periods of the disease is not very conspi- 
cuous when the recurrences are themselves slight in character; 
as there is not then the contrast between marked good and bad 
health, or between the more disordered condition and that of 
imperfect recovery, which renders the assignment of the dis- 
ease, in the opposite cases, comparatively easy. Thus it will 
often appear, that there is a continuous disease enduring for long- 
periods; while this may sometimes be the fact in reality; or else 
the intervals may be so short, and the recurrences so frequent, 
that they can scarcely be defined. 

Supposing, on the other hand, the reverse case, or a recur- 
rence of decided intervals with relapses, one of the simplest 
and best marked, is that where the patient, in the vulgar eye, 
is subject to fevers, as it is called. In such cases, there is a dis- 
tinct fever, running a regular course, though as a fever common- 
ly slight in character, unless under gross maltreatment, and 



64 CHRONIC AND OBSCURE 

terminating in health; when, after an interval varying from 
weeks even to months, it returns, from a distinct cause or not, 
again to subside into health. 

In these cases, by no means uncommon, while there are end- 
less varieties in the lengths of the intervals, the duration of the 
fevers, or relapses, also varies; though, as far as my experience 
has gone, the longer are more common than the shorter ones. 
Thus I have more frequently seen periods of six weeks than of 
one; although, even in the same patient, it will happen that suc- 
cessive relapses will put on every period of duration to which 
a single attack of this fever is subject. 

When, now, the relapses or returns occupy the longer pe- 
riods, such as that of six weeks, or a month, while the inter- 
vals are short, extending, as is not unusual in the worst cases, 
not beyond a week or a fortnight, and while in such cases the 
patient, particularly if debilitated by a long continuance and 
frequent repetition of the disease, or naturally of a feeble con- 
stitution, has scarcely time to recover his health until the next at- 
tack comes on, he often appears, both to himself and to his phy- 
sician, to labour under a continued state of feverish bad health, 
or even of absolute fever, lasting through many months, and 
even through years. 

These, then, are opposed extremes, as to recurrence in this 
disease; and, between the two, there will be found, in practice, 
innumerable varieties, which I need not detail. And, however 
obscure, however even mysterious, such a state of disease, con- 
tinuing so long, and producing no ultimate bad effects, may ap- 
pear to an ignorant or inattentive physician, a more watchful 
reasoner, he who applies philosophy where others follow blind 
rules, -will rarely if ever be at a loss in tracing, not merely the 
relapses and their intervals, be they as obscure as they may, but 
the diurnal variations of the disease itself during the continu- 
ance of the proper accession. 

With respect to the duration of this relapsing or habitual re- 
mittent, it is as various as every thing else; as various as that 
of the chronic intermittent, be it tertian or quartan. I have 
seen it last one year, two, three, twenty; nor is it more won- 
derful, doubtful as the fact, thus stated, may appear to those 
who have not studied or known this disease, that a quotidian 
periodical fever, be it called quotidian or remittent, should last 
twenty years, than that tertians and quartans should be equally 
permanent; as they are well known to be. And if any physi- 
cian should doubt this statement, as, personally, I have found it 
doubted or denied by every one with whom I have communi- 
cated, I must again refer to France and Italy for the proofs: 
since this is exactly what happens to all the wretched inhabi- 
tants of their pernicious districts, whose condition was pointed 



REMITTENT- 65 

out in the essay on Malaria. And there is the same reason for 
its occurring in our own country, if all that I have been at- 
tempting to prove is established: while, in truth, it is known, 
or may at least be seen, by any practitioner in our fenny coun- 
ties who will make himself master of this subject as I have been 
discussing it. 

-Of the causes that may render this fever thus durable, I have 
formerly mentioned a residence among the sources of Malaria, 
or, as it is popularly considered, in a damp or unhealthy situa- 
tion; or the frequent exposure to such causes, from ignorance 
or necessity. And we can now see more distinctly, the impor- 
tance of the cautions laid down in the former part of this work 
respecting soils and situations; since this is the "bad health" 
of which they are the ordinary cause, and since it is matter of 
ample experience that the avoiding them is often the only me- 
thod of curing the disease, though, when long established, even 
that often fails. 

Besides this original cause of all the evil, however numerous, 
other causes inducing debility will reproduce the relapse, and 
thus tend to perpetuate the disease; and the more readily as it 
is a more confirmed habit. Such are ordinary cold, fatigue, in- 
toxication, bleeding, the excessive use of saline purgatives, men- 
tal affections, with others unnecessary to name; all of them 
equally efficacious in recalling the returns of a chronic tertian 
or quartan. Of all those causes, I would particularly notice 
here the use of purging, and mental affections; as, respecting 
the other, no one doubts much, and as they are commonly 
avoided. That what is called "a course of salts" will very 
often reproduce an attack, I have abundant proof; and it is es- 
pecially necessary to notice this, since it is commonly resorted 
to as a remedy for the imagined diseases to which the symp- 
toms of this fever equally belong. Hence the frequently inju- 
rious effects of that fashionable folly, the frequenting of mine- 
ral wells; a practice resorted to by presumptuous patients, or by 
vulgar practitioners, as if it must be univer^^y salutary and 
was incapable of doing harm. And the cc" inmon error in this 
case, as it is the especial cause of this erroneous and pernicious 
practice, is the mistaking the derangements which I formerly 
noticed for dyspepsia, as it is ca^ed, or liver complaints, or 
whatever else, under this received phraseology which is now so 
current; while the empirical practice to which I then alluded 
is applied without examination. 

The mention of blood-lettipg also induces me to offer, here, 
another caution on that sublet, (though it is a question which 
will be fully examined # treating of the cure,) should local 
pains, not unusual in this disease as I shall presently show, ap- 
pear, in ordinary hanas, to justify it; since by this error, here 

9 



66 CHRONIC AND OBSCURE 

as in chronic intermittent, the disease is invariably aggravated,, 
and commonly prolonged or perpetuated; too often also with 
the addition of many other distressing symptoms. As to the 
influence of mental affections, it is rather a matter of curiosity 
than use, as the injurious occurrence of these can scarcely be 
guarded against; but it is, in the philosophy of physic, an inte- 
resting fact to observe, how instantaneously sudden grief, fear, 
disappointment, or other strongly depressing passions, will bring 
on that relapse which will generally run the same course as all 
the preceding. 

It is a common opinion in physic, that a fever of this nature 
cannot exist without organic disease; and I presume I need 
scarcely say that such habitual fever has been often considered 
and called a hectic, the produce of such disease. Of hectic, 
the real produce of organic disease, no one can doubt, nor of the 
singularly periodical diurnal character by which it resembles 
remittent fever. But it is highly necessary not to confound 
things so essentially differing; while the distinction assuredly 
often demands great attention on the part of the physician. And 
from numerous cases, of such a nature as to leave no doubt 
whatever, I am convinced that such chronic fever, bearing all 
the characters of this imagined hectic, do exist without any or- 
ganic disease, and even for long periods; since, while not the 
least symptom of such affections could be traced during their 
continuance, the absolute and entire recovery of the patients, 
and a recovery lasting for the remainder of life, has followed. 
Nor needs this be doubted, when we see that intermittents, 
equally chronic and durable, and where also organic disease had 
been suspected, terminate in perfect health, lasting equally 
through the patient's life. It is too common for physicians, in 
thsse cases, to suspect organic disease, because it sometimes ex- 
ists, aaid, as I before remarked, because they have formed an 
hypothecs that nothing but such a permanent exciting cause 
could perpetuate or thus prolong the febrile diseases of Malaria. 
As to the question f hectic, I shall not now pursue it, because 
I must again notice > when on the subject of intermittent; when 
I shall also point out so^ e circumstances which facilitate the in- 
vestigation and distinction 

Respecting the organic auctions, I have already shown rea- 
sons for avoiding that discussion here. I can but allude to a 
class of disorders ro which 1 dare not give the space which they 
would require, But I must distinguish at least, lest I should 
be supposed to give less value to these affections as connected 
with chronic fever of this nature, than they amply demand. I 
have said that the mild disorders of inis kind may exist with- 
out organic derangement, or without conspicuous affections of 
this character, not that they always do to. In our own coim- 



REMITTENT. 67 

try, however, I believe, this is common; and particularly where 
the original fever, or the habit of such disease, has been ac- 
quired accidentally, or by transient exposures to the cause; 
where it is not maintained as it was produced, by a permanent 
residence in a pernicious district. In the reverse case, there 
is more cause for suspicion; and it will frequently also, it is 
probable, be found that there is organic disease present: though 
when this is not considerable, the difficulty of ascertaining it is 
often great, particularly in the case of the spleen. In such 
cases as I allude to, it is plain that the circumstances resemble 
those which characterize the pernicious climates of France and 
Italy, however inferior in power; while in those, independent- 
ly of what is asserted or believed by foreign physicians, we 
might infer that the organic diseases were a frequent or general 
accompaniment of the fevers in question, whether considered 
as rigidly necessary to their existence or not. 

With respect to this chronic remittent, I ought to add one 
more practical remark. It is, that other circumstances being 
equal, it will, in practice, or, as a disorder calling for medical 
aid, occur more commonly among females than males, (or thus 
at least it has occurred to me,) and also be more apparent to 
physicians in the higher than the lower ranks. The causes of 
this are of a moral, not of a physical nature, or at least predo- 
minantly so; though the greater delicacy or irritability of fe- 
males may render them greater sufferers, in reality, under slight 
modes of this disorder. The moral causes are, abandonment 
of mind, self-indulgence, luxury: conditions on which I need 
not dwell, and which I need not apply more particularly, but 
which, it is evident, aggravate all slight diseases, not merely to 
the eyes of the physician but to the feelings of the patient. And 
reversely, while courage, exertion, or resolution not to submit to 
aught but absolute necessity, diminish the effects of all such dis- 
eases on the patients, it is further true, that a powerful exertion 
will often terminate the accession altogether; just as similar ef- 
forts of mind often cure intermittents, and have removed even 
gout, ordinary fever, and other diseases. 

I must however also remark, that there is a not uncommon 
physical reason for the greater suffering of females in this dis- 
ease; and it arises from the menstrual derangements which I 
formerly noticed; which, however they may be an effect, and 
not a cause, appear in themselves to produce injurious conse- 
quences as to the health. Whether from this cause, or from 
the general state of disorder in the system, it is a circum- 
stance also demanding notice, that in severe and continued 
cases, barrenness is not an unusual occurrence; commensurate 
with its appearance, and when shown to be removed, by in- 
dications of pregnancy, giving often the first decided evidence 



0J> CHRONIC AND OBSCURE 

of the termination of the whole disease. That anaphrodisia oc- 
curs in an analogous manner in the other sex is no less true. 

I might perhaps safely still add to these, another cause, and 
of a physical nature as to its action; however dependent on men- 
tal circumstances, but on manners rather than morals This 
is the comparative uniformity of occupation and of residence to 
which females are subjected: a uniformity which, with res- 
pect to the latter, when such disease is present, may, and does, 
become a continued life of seclusion or confinement, with the 
addition of indolence, self-indulgence, or utter listlessness both 
of mind and body; and of a mind also which, but too often ne- 
glected, possesses neither power to act nor ideas to act on or 
with. In those cases, there is nothing to break the habit of dis- 
ease once acquired, as there is no mental or bodily action to op- 
pose it; and I have, here, more than once, shown how the chro- 
nic diseases of this nature are dependent on habit. As the re- 
verse of this, it is superfluous to point out the various circum- 
stances in the opposite sex which tend to remove or counteract 
these influences; since they are obvious. Nor need I now sug- 
gest to physicians, that which they must so often have seen con- 
firmatory of this; while numerous cases resembling those which 
Haygarth has pointed out, and which seem to me to illustrate 
these very facts, probably, among others, must be familiar to 
every practitioner versant with the opulent and unemployed 
classes of society. 

I must now state the progress of a single accession or relapse; 
as there are variations in that, which demand notice. As a point 
of comparison, the original attack of a remittent of the more se- 
vere form, is frequently, perhaps geuerally, by a cold fit, and 
often as decided and severe a one as that of intermittent. But 
in the progress of the disease in the mild form, as generally also 
in the severe one. the cold fit disappears, or becomes at least 
difficult to trace. Still, there are often indications, consisting 
in partial cold feelings, or the affection of particular spots in the 
body, in the asperity, acceleration, and contraction of the pulse, 
in yawning or stretching, often attended with an indescribable 
feeling of uneasiness which seems to penetrate every muscular 
fibre of the body, in a sensation resembling that which the ex- 
cessive use of tobacco produces in those not habituated to it, or 
in a shrinking and paleness of the skin, or even in a mere alte- 
ration of the physiognomy, sometimes felt in the muscles of the 
face by the patient himself, at others, visible only to the watch- 
ful and discerning spectator. 

Thus also in the chronic or prolonged remittent, it sometimes 
happens that the first paroxysm of the new accession or relapse 
is attended by a marked cold fit, while, in every succeeding 
one, nothing can be found but one or other of the symptoms 



REMITTENT. 6.0 

just mentioned, and sometimes not even those. Again, it hap- 
pens, that the cold fit, however short and slight, is sensible at 
the commencement of each daily paroxysm, or at least for some 
time: and thus the disease acquires the character of a chronic 
quotidian, as this is the boundary by which these two congene- 
rous diseases can alone be easily separated. In other instances, 
the commencement of the relapse is marked only in the sto- 
mach, by a total and almost sudden loss of appetite, sometimes 
attended by a slight nausea. And again, it is not uncommon 
for the disease to proceed as it commenced, in a manner so uni- 
form, that scarcely any indication of a cold stage can be traced 
-through its progress, while it is seldom that the physician has 
an opportunity of witnessing its commencement. 

Such is all that it appears necessary to say in addition, re- 
specting this fever as a chronic or habitual disease, while, as 
such, it may possess any or all of the symptoms described as 
belonging to the simple disease, and which I need not repeat; 
and while, particularly, it is not uncommon to find it associated 
with the local and painful disorders that will be described here- 
after. But before quitting it, I must also add, that although in 
the description of the mild remittent, I have spoken of it as if 
it were a disorder limited to one period of fever or to a single 
disease, for the sake of simplicity, it is rare that this is the fact; 
and the description then given of it must in reality be considered 
as most generally that of a chronic disease; of the fever just dis- 
cussed, which becomes habitual, or has a tendency to relapse 
through a period of months or years. 

But before terminating this portion of the subject, it will be 
useful to recapitulate in a brief summary, the characters of this 
fever, and to add one, equally brief, of the proofs of its cause 
and nature; that the reader may see in a condensed form, what I 
have been obliged, for the sake of proofs and illustrations, to treat 
of in some detail. And this is the more necessary, from the evi- 
dent neglect which this disorder has experienced, and from the 
great errors daily committed respecting it: errors, such and so ge- 
neral, that it is somewhat difficult to find a practitioner who seems 
truly aware of its existence, and, on the contrary, much more 
common to experience the incredulity, both of physicians and 
patients, when attempts are made to demonstrate its presence, 
or, by this, to explain the obscure derangements of health in 
question. So difficult is it to introduce new views among those 
who are guided solely by habit, and not by observation; and so 
singularly contradictory is the conduct of physic, which, while 
it complains of the general imperfections which it acknowledges, 
always meets attempts at improvements in the details, with an 
opposition which implies that it possesses no imperfections, but 
that we have arrived at a complete knowledge of this truly ob- 
scure science. 



70 CHRONIC AND OBSCURE 

When the disease in question is mistaken for consumption, for 
dyspepsia, for hypochondriasis, for atrophy, for " nervous dis- 
order," and, if with local affections, for many more diseases, 
even for palsy, it is fully time that its real nature should be ex- 
plained and understood; as the sufferings which it. produces are 
scarcely exceeded by those of any disorder in the catalogue, 
and as these are not merely endured as incurable, but since ad- 
ditional diseases, and even death, are the frequent result of er- 
roneous practice under false views of its nature. 

If this obvious disease has been so much overlooked or mis- 
taken, I doubt not that it will shortly appear to be very com- 
mon, now that it is distinctly pointed out. And perhaps, the 
explanation which I will now suggest may also form that apo- 
logy which every just critic is bound to find when he can. 
England is so generally free from the intermittent fevers which 
form the readiest road towards its analysis, or towards even the 
ready knowledge of common remittent, that out of thousands of 
medical men, and especially in the metropolis, there are hun- 
dreds to whom they are unknown; as may also be truly said 
with respect to their causes, or to the existence of Malaria and 
of places generating it: a subject however less pardonably over- 
looked, and perhaps chiefly so from the perpetually mistaking 
remittent for typhus. And further, as it is from books chiefly 
that the great majority of ordinary practitioners draw their 
knowledge, they do not see a disease of this nature unless it be 
marked as books mark it, severely and distinctly: while, I may 
add, that from limiting themselves chiefly to English and to 
modern, and also to systematic writers, they exclude them- 
selves from a knowledge which could scarcely be acquired but 
in a very different course of reading, if indeed it could even 
thus be attained. 

Hence an ignorance which is somewhat excusable, naturally 
enhanced by what is less to be excused, the viewing diseases as 
definite events under definite terms, instead of generalizing them 
by means of analysis and analogy. If remittent fever in its or- 
dinary form is somewhat better known, and if a due study of 
this disease might have led to the conclusions here drawn, yet 
has this also been too generally misapprehended, both as to its 
nature and its cause, as I have often shown; remaining a subject 
of vulgar error as to its theory, and of empiricism in practice. 
Such is the apology; nor can it be otherwise, while, in the very 
great majority of those who pursue physic, it is a mere art, or, 
in reality, a trade, not a philosophical study as a branch of na- 
tural history: and he would be an unreasonable critic indeed who 
should expect from a manufacturer of mathematical instruments 
or of chemical drugs, that which he ought to seek in the Aragos 
and the Barlows, in the Gay Lussacs and the Daltons. Physi- 
cians themselves, at least, know that this is a just view of the 



REMITTENT. 71 

state of this art and science; as it were unreasonable to expect 
that it could be otherwise: if the public commits the very na- 
tural error of supposing that the art and the science are the same 
thing, they must not imagine that censure is passed when there 
is merely drawn an acknowledged distinction 

The summary, now, which, having explained the causes of 
the neglect of this disease, I would give, is the following. 

It is a remittent fever, bearing all the characters of that dis- 
ease as it is universally known; but in a modified degree, and 
often so slight, as to require some attention in tracing its form 
and even its existence. 

It is apt to become habitual, or to recur at frequent but varia- 
ble intervals, during an indefinite course of years, so as even in 
some instances to occupy almost a long life. In such a course, 
it also varies its characters and symptoms, and in some cases, be- 
comes a marked chronic intermittent; while in others, the im- 
perfection or brevity of the intervals may cause it to appear as 
a continued febrile state. 

Its accessions, when they are to be defined, are as various in 
duration as those of the ordinary severe remittent. 

It is the sequel, in some cases, of quotidian intermitttent or 
of double tertian: and if a mild fever of this nature follows a 
common tertian, the length of the interval will oblige us to rank 
it under tertian, as a chronic disease. It is also the sequel of 
common and acknowledged remittent; and thus it may also be 
a sequel of what is called typhus fever, because the remittent is 
often thus misnamed. It is equally a sequel of what is called 
low fever or nervous fever, which, equally mistaken for a mild 
typhus, is a remittent. And these also are the proofs of the 
real nature and origin of this disease; since it is their continua- 
tion, or forms varieties under them. And, while its causes must 
be sought in Malaria, (though others are not absolutely excluded, 
in our present state of knowledge) even when it occurs as a pri- 
mary disease, this also establishes, even further if that were ne- 
cessary, its true nature. 

Such is the simple disease: a chronic or relapsing fever with- 
out accessory symptoms; or rather, without incidental, or at- 
tached, or superfluous symptoms. I need not here dwell on 
the ordinary attached or necessary symptoms of all fevers: but 
it will be especially useful to recapitulate, or further point out, 
all those which, belonging to this disease, may also arise from 
other causes, or may be original or separate diseases; because 
to mistake those in this manner, is the greatest source of the er- 
rors which occur in practice in respect to this disorder, whether 
as regards the diagnosis, (as it is termed,) or the treatment. And 
when they are of a marked nature, while the mere fever is 
slight, or when the practitioner is of that class which never pe~ 



72 CHRONIC AND OBSCURE 

netrates beyond a symptom, or when as the slave of names, a 
symptom is to him a disease, or when, lastly, with even better 
discernment, such symptoms are erected into diseases because 
there are other disorders in which they are the obvious or essen- 
tial part, for which the varieties of this fever are thus mistaken, 
it is most certain that the errors which I trust this enumeration 
may at some distant day correct, must have been, and still are, 
frequent and serious; in proof of which I might, with great ease, 
produce cases that would materially enlarge the bulk of this vo- 
lume. 

These varieties, or the chronic remittent with superfluous or 
attached and unessential symptoms, or with some of its symp- 
toms peculiarly distinct, or aggravated, and the more deceptive 
when the mere febrile condition is slight, compose what the ti- 
tle of this chapter means by anomalous remittents. Hereaf- 
ter, where the intermittents of an analogous character are re- 
viewed, I have adopted also the term simulating; not that it 
would not have been equally justifiable to introduce such a di- 
vision here, but because I have not seen examples of this mode 
of marsh fever where the simulations have been so numerous 
and perfect as I have found them under the more distinct types, 
or in those cases where the febrile state and the peculiar symp- 
tom, or disease, with it, were derived from some form of inter- 
mittent, Hence I have reserved the whole of the simulating 
marsh fevers for one chapter to follow that on intermittents; 
though I am bound here to observe that some of them have oc- 
curred also in the chronic disease now under review. If 'I had 
been permitted to treat of remittent and intermittent fevers both, 
under one general head, I should have avoided, not only the 
present inconvenience but much repetition; but I must submit 
to received usages, as the reader must to the additional toil. 
Whether the few varieties which will now complete this chap- 
ter should be called anomalous or simulating, deferred till I treat 
of intermittent or described now, is one of those undetermina- 
ble questions of arrangement, of which there are here but too 
many more; so undefined are often these irregular disorders. 

It is with little reflection assuredly that debility is considered 
as a disease; yet is this condition, one of the marked symptoms 
of the disorder in question, often to be found, in military re- 
turns in particular, as if it could be an independent disorder. 
From how many other sources it may arise, it is not for me here 
to inquire: it is enough that it is one of the very general effects 
of that febrile state, in this disease, which, from its slenderness, 
or from the brevity of the attacks, or from negligence, is so fre- 
quently overlooked. And that thus mistaken, and of course 
neglected, when arising from this fever, it is a very common 
source of trouble and misery to patients, just as, in soldiers, it 



EEMITTENT. 73 

leads to suspicion of fraud, as was formerly suggested, I have 
abundantly ascertained. 

Lest however I should be thought to have overrated this class 
of error, (though military physicians of real learning will, I be- 
lieve, scarcely disagree with me,) I may quote the celebrated 
Morbus Pannonicus of Hungary, or the Morbus Hungaricus of 
Jourdan and of Manget, as also an analogous disease formerly 
much noticed in Virginia, described by the name of the Asthe- 
nia Virginica. No doubt can remain on the minds of those who 
will read these histories under the views which I have here af- 
forded, that the former disorder, under which so many soldiers 
died, was the chronic fever in question, rendered mortal, it is 
probable, by bad food and bad treatment: while, with no small 
blindness on the part of the narrators, every cause but the true 
one is assigned; such as drinking bad water, the heat of the cli- 
mate, bad food, and much more; many of them, doubtless, con- 
nected with the mortality; yet but as incidents, or as belong- 
ing to the cause of the disease, inasmuch as producing the pre- 
vious fever in question, which was overlooked. 

Thus when thirst is the most vexatious symptom of this fe- 
ver, it is, if not marked as an independent disorder, supposed to 
arise from some mistaken cause, while it is a mere symptom of 
the febrile paroxysm. 

Indigestion, loss of appetite, irregularity of bowels, these and 
other ordinary symptoms of a deranged stomach, are thus attri- 
buted to dyspepsia, as I have already remarked; an undefined dis- 
order arising from many causes, and scarcely to be considered in 
any case asoriginal and simple: while the error is confirmed when 
occasional thirst, headach, debility, and other well-known symp- 
toms of this disorder are present, and when these accessory ones 
are the symptoms of the fever. Thus also the affections of the mind 
which are notoriously the produce of chronic remittent, are con- 
ceived to be the hypochondriasis of dyspepsia; while that which 
is called the hectic of dyspepsia will often be found to be nothing 
more than the fever of this disease; rather, the very disease it- 
self, and the cause of all the rest. 

And if such dyspepsia, as a chronic and endemic disorder 
among the people, in all the insalubrious or marshy situations 
in France and Italy, has often been pointed out by the physi- 
cians of those countries, it is not less true that it exists even in 
our own island, as a similar endemic, and from the same cause; 
confirming the view here given of its occurrence in single cases, 
and in a manner so apparently independent of such fever, as to 
be mistaken for an original disorder, or at least for a disorder 
dependent on some other and separate cause. It is from infor- 
mation, however, not from present observation, yet from infor- 
mation which appears worthy of reliance, if I here state, that 

10 



7.4 CHRONIC AND OBSCURE 

in certain parts of Hampshire, and in some other of the districts 
subjected to Malaria, the general, and almost the only complaint 
made by the mass of the common people suffering under the 
chronic disorder in question, whether as the sequel of acute fe- 
ver or otherwise, is dyspepsia, or, as it is expressed by them- 
selves, "the stomach." And while this leads to erroneous 
judgment and erroneous practice in the hands of those who are 
unaware of the real facts, so does that leading symptom, viewed 
under the fashionable prejudices of English practitioners in the 
present day, produce that injurious and often destructive prac- 
tice to which I already took occasion to allude. 

What are called nervous symptoms, a list that would weary 
human patience to specify, but which cannot require enumera- 
tion, are, further, most common symptoms of this chronic fever, 
while the fever itself is invisible or unnoticed: and there are 
perhaps few errors with regard to it more common, than that of 
designating it under this cloak for ignorance, and treating it ac- 
cordingly: though, fortunately in one respect, the remedies of 
change of place and air, so commonly resorted to for " nervous 
diseases/' are the cure of this one; if that good fortune is not 
in some measure counterbalanced by the ignorance as to the true 
cause which is thus perpetuated. And, of that ignorance, the 
leading evil is, that this cause is not avoided by the different 
migrants or travellers: who thus, often, not merely lose all the 
advantages which they would have gained from change, but 
much too frequently plunge headlong into the very dangers 
which they ought most carefully to shun, and most frequently 
in the case of travelling to the warmer climates of Europe. 
This is a subject which I have noticed in the essay on Malaria, 
but which I ought not to avoid repeating, important as it is; 
since it is most certain that the evil consequences to which I 
here allude are very frequent, and have been especially common 
since travelling has become more easy and more general. I need 
not dwell on hysteria, thus mistaken, after what I formerly said 
respecting it; the more as I shall have occasion to notice it here- 
after as a symptom of intermittent, and as often producing there, 
a truly simulating and deceptive disease. All that I need re- 
mark is, that if the hysterical paroxysm should be conspicuous? 
and the febrile symptoms obscure or gentle, or if the uninformed 
practitioner should overlook the one, to notice the other and 
more striking, this fever will be mistaken for mere hysteria, as 
I have often witnessed. And if in such instances the paroxysm 
may be as regularly diurnal as the febrile attack to which it be- 
longs, so may it be irregular, by missing to return; in which 
case it will become still more difficult to convince the attendants 
of its real nature, as the insufficient practitioner will also more 
easily mistake it for an original and independent disorder. 



REMITTENT. 75 

If I might, here, have entirely reserved the case of headach, 
considering it as a local disease, and thus placing it in the same 
division with all those more purely topical disorders, chiefly of 
the nerves, to which I can here but allude as connected with re- 
mittent, and if, in fact, I have been obliged so to treat of it 
among the intermittent topical diseases, I cannot still avoid 
speaking of it here, as being one of the most common of the 
anomalous appearances of this fever; while, like the stomach, 
such is the nature of this part, that its disorders may almost 
equally be considered general as topical; and the more so as the 
headach is a leading symptom of all fever. 

It will be found on a strict investigation, that many of the 
durable or chronic headachs are merely those which belong to 
this fever; and while, as lately remarked, it would appear that 
the female sex is more subject to headach than the male, from 
whatever causes arising, so I have observed that, in the habitual 
remittent, it is more common as a symptom in women than men. 
And in more than one patient, I have found that where this dis- 
ease was habitual, some of the accessions, or distinct periods of 
fever, consisted in a series of headachs alone, while others bore 
their ordinary character; or at least this symptom was so pre- 
dominant, that the accompanying febrile disease would have es- 
caped the notice of an ordinary practitioner, as it did of the pa- 
tient; perhaps even of a more acute one, had he not been able 
to trace the previous progress, and not been acquainted with the 
whole history of the patient. To know that such may be one 
mode of the chronic remittent, is important, considering the 
frequency and the obstinacy of this disorder, the headach, and 
the numerous causes from which it appears to arise: while the 
proofs of its identity or connexion, consisting in what I have 
now stated, will be found by any one who will study the disor- 
der which I have here described. 

For what else I might have introduced into this chapter, I 
must refer to that on the simulating intermittents: and if there 
is a considerable division of symptoms or diseases which might 
also have found a place here as connected with this chronic fe- 
ver, the division which I have been compelled to adopt for the 
sake of the proofs, obliges me to defer them to a future part of 
this essay. 

If I have hitherto quoted no authorities in support of these 
views respecting the chronic remittent, it is not solely for the 
reasons hereafter given in explanation of the plan adopted in 
this essay, and which were also hinted in the preface. I have 
not succeeded in finding among the authors whom I have con- 
sulted since this essay was drawn up, (though that is not a small 
number,) any detailed histories, nor even any general views. 



4 
76' PROXIMATE CAUSE OF 

whence I could have derived such support: excepting, that as to 
particular facts, I have found many valuable ones noticed under 
the head of intermittent types, which I have consequently ac- 
cumulated for illustration in a subsequent chapter. 

But if I have not found in such books, descriptions whence I 
might have drawn, or by which I might have supported my own, 
no details, no account of such a chronic fever, I cannot for a 
moment doubt that it must be perfectly known to the French 
and the Italian physicians; though so completely overlooked by 
our own writers and practitioners as far as those are known to 
me. This disorder, in all its varieties, must not only exist, as 
I have already said, but it must even be the habitual state of dis- 
ease or suffering, otherwise than as intermittent types may share, 
in all those European countries where Malaria is severe and its dis- 
eases the endemics of the soil. This must, in fact, be the per- 
petual state of fever, under which it is said, by all foreign, par- 
ticularly French, writers on this subject, the unfortunate inha- 
bitants exist, such as that existence is: and if they have not en- 
tered into details, it is possibly because it appeared to them too 
common and familiar, too well known to require such a history: 
forgetting perhaps, as is not unusual, that any one could be ig° 
norant of what, to them, did not appear to demand teaching. 



CHAPTER III. 

On the proximate Cause of Remittent or Marsh Fever. 

I believe that it will be a phenomenon in medical writings, 
to find an essay on such a disease as fever, unattended by a theo- 
ry of its proximate cause. Yet were it as well, if the professor 
who spends months in exciting the wonder or applause of a ju- 
venile audience, with phraseology which he does not himself 
understand, would substitute for all this waste of words and time, 
the confession of his own and the general ignorance, if his suc- 
cessor would, strive after something more useful than inventing 
a new system, of which the only merit lies in the difficulty of 
finding new forms of phraseology equally unintelligible; and it 
would also be no small advantage, if the time of students, sel- 
dom too abundant for all that is really to be learned in physic 



REMITTENT. 77 

and its collateral studies, were occupied in something more pro- 
fitable than disputations about words, reading as idle, and attend- 
ance on wordy lectures, more idle than all, inasmuch as they 
are the cause of all this perversion of time. Then also would 
medical writings shrink in size and diminish in number: con- 
summations all of them, to be wished, but not to be expected 
while words shall usurp the place of ideas; as long as the sub- 
stitution of one term for another shall be considered philosophy, 
and the word logic be an empty and an unmeaning sound. 

Where ignorance exists, the consciousness, with the confes- 
sion of ignorance is, if not the first step to knowledge, the pre- 
liminary and the necessary one; for never yet has philosophy 
thriven by dressing up fiction and vain speculation in the garb 
of truth and sense. Physic knows not how the poison of fever 
acts, nor on what it acts; what are the preliminary effects which 
produce the symptoms which are obvious to our senses. It can- 
not even conjecture why these actions should cease, why they 
should be renewed, and with a regularity, often not to be ex- 
ceeded by that of a machine, or why they should cease to be 
renewed. 

Doubtless, the inquiry is a most interesting one; but how can 
we inquire when we have not the slightest element ascertained, 
on which an inquiry can be founded? We know not where to 
begin: it is to solve a problem in dynamics without weight, 
time, or velocity; to analyze an unknown substance without the 
means of analysis, when we do not even know that it is a com- 
pound one. That what is now impossible is always to be so, is 
not however what I mean to insinuate; far from it; but as the 
career of philosophy has proceeded through facts, and never did 
advance one step while it toiled through words, so must physic 
submit to follow the same and the only road. When we under- 
stand the physiology of the animal body, we shall have laid the 
foundation of a knowledge of its pathology, and, with that, it 
will be time enough to attempt an inquiry into the proximate 
cause of fever. If there is any one who, leaving his schools, 
or who, confined to medical writings, and knowing only medi- 
cal laxity of reasoning, fancies that he understands physiology, 
even, I may say, any one point in physiology, let him pass a 
few years in the study of the accurate sciences, in the mathe- 
matical ones, and in chemistry, and in the habits of a rigid logic, 
and let him then return to his medical writings and question him- 
self. He will not require the answer that could easily be given 
to him. 

Yet, though averse to enter on this endless subject, and very 
especially on any of those speculations which are either inno- 
cent in themselves or have now lost their influence on practice, 
I cannot well avoid noticing some recent doctrines of this na- 



78 PROXIMATE CAUSE 0£ 

ture, which are as little proved, though perhaps more plausible; 
while productive of, or threatening, dangerous consequences. 

I shall leave that theory which represents fever as consisting 
in inflammation of the brain, to the answers which it has alrea- 
dy received. The action of Malaria, say the French, is 
^sthenique," and the various symptoms of debility are the ef- 
fect of exhaustion from the previous stimulus. The natural 
question is, what or where is an excitement or a sthenic effect 
which does not occur at all in innumerable cases. If indeed 
the action of prussic acid, or lightning, or a cannon shot, is 
sthenic, then the assertion will not be disputed: and thus he who, 
under the action of Malaria, falls down instantaneously with 
apoplexy, has died of over-excitement. 

The fever of marshes, say others, under whatever form, is a 
gastro-enterite; or, essentially and radically, it is but an inflam- 
mation of the inner membrane of the stomach and bowels, one 
or all; and every other effect and symptom is sympathetic or con- 
sequential: or " adynamique," arising from " sur excitation. 53 
On this is the practice founded, by those who thus believe in 
the last new theory; while, it is said, the success of the practice, 
consisting in bloodletting and so forth, proves the truth of that 
theory. Let us inquire as to both: to say nothing of the evil 
results which flow from acting upon this fashionable hypo- 
thesis. 

But first of all, how can such an inflammation, and of such a 
membrane as this, generally, is, produce so deadly, so universal 
a disease; a disease so abounding in symptoms, present and sub- 
sequent, so endlessly varied, and so fatal? The stomach, and 
the bowels also, are often much more and more extensively in- 
flamed, and without such fever, or such symptoms, or such ef- 
fects. In these fevers there is often no pain, not even on pres- 
sure; and where then is the inflammation? Thousands of persons 
die with all the symptoms of this fever, even within a few days, 
within a day, within an hour; the gastro-enterite, here, ought 
to be excessive, yet there is none, for there is no pain. There 
is none, for a much better reason; that it is not found on dissec- 
tion. We may refer to a thousand authors, for thousands of dis- 
sections, where, if the bowels and stomach have sometimes been 
found inflamed, there has not been the slightest trace of pre- 
sent or previous inflammation in numbers without counting. 
And if this were not enough, we find patients who die of fevers 
with very slender symptoms, where there has been no pain; 
and yet dissection proves the bowels to have even been serious- 
ly ulcerated. If inflammation had killed the patient in any 
ease, how is it to disappear and leave no trace? and what spe- 
cies of essential cause or symptom is that which is not always 
present? 



REMITTENT. 79 

Whatever dissections have taught, they have not taught us the 
cause of marsh fever; and let he who doubts, read all the mon- 
strous volumes on this subject. They have taught us that cer- 
tain effects take place occasionally: that is their use: and the 
gastro-enterites, the inflammations, be they what they may, are, 
in reality, symptoms or effects: how far they must regulate the 
practice, is a question not for this place: but let them regulate 
it in as far as they are such, not as being the essence and the 
proximate cause, and then they may effect good and not harm. 

It is scarcely worth while to ask, after this, what kind of in- 
flammation that must be which can return periodically, and with 
such severity as to destroy a patient, and yet have no existence 
within another hour. If I have elsewhere shown that an inflam- 
mation connected with intermittent really possesses this singular 
character, it is a fact which will not invalidate the much stronger 
arguments already brought forward. This sole objection, which 
has been urged against the French theory, is not therefore, in 
itself, valid: because when it is asked how can an inflammation 
cease, return, or last for life without causing much mischief, it 
is forgotten, or rather it was never observed, that the ophthal- 
mia of this character w T as the inflammation of intermittent fever; 
while the caprices of gout, erysipelas, and rheumatism, show 
that this is no uncommon occurrence. It is, in reality, an in- 
flammation of a peculiar character; sui generis, distinct from 
common inflammation: and hence also the supporters of this 
theory may retort, (though from want of making this most ne- 
cessary distinction, here I believe first decidedly pointed out, 
they have not done so,) that the fact of its being cured by bark 
and stimulants is not an objection, because this is precisely what 
happens in the intermittent or neuralgic ophthalmia. 

But I need not proceed; as I hold that the answer is complete. 
As to the schismatic theory of Monfalcon, who considers the 
whole matter to consist in a predominance of the white capilla- 
ries above the red, in an unusual " develloppement du systeme 
lymphatique," and a " subordonnement des capillaires sanguins 
aux blancs," I presume we may rank it with Dr. Cullen's proxi- 
mate cause of rheumatism, which consists in an " inflammatory 
affection of the sanguiferous system, with a peculiar affection of 
the muscular fibres." I shall pass on to the cure of remittent 
fever. 



[ SO ] 



CHAPTER IV. 

On the Cure of Remittent Fever. 

I must commence here, as before, by renouncing all inten- 
tion of treating of this part of the subject as it relates to the se- 
vere remittents of the hot and tropical climates. I need not 
compile when I can refer; nor could I speak with confidence 
of the cure of diseases that I have not witnessed and treated. 
Nor indeed would it be an easy task to elicit the truth amid the 
disputes and contradictions which are found to pervade those 
endless works. The most opposite opinions have been enter- 
tained, and the most opposite practices followed. As happens 
in tetanus, all these modes have failed, all these modes have 
seemed to succeed. The conclusion of him who knows nothing 
of ph}-sic, will probably be that the imagined remedies have 
had no concern in the cures, though he will scarcely conclude 
that they have had none in the ill success; while a fatalist in 
medicine, as fatalists there are, will perhaps determine that the 
efforts of the physician are nugatory as to either event. 

In our own country, there have been similar discordances of 
opinion, with corresponding revolutions of practice, from the 
time of Sydenham downwards. In the days of my own edu- 
cation, at Edinburgh, the great, and indeed, almost the exclu- 
sive remedy for all fevers, was wine. I returned a few years 
afterwards, to find wine out of fashion, and to see the same dis- 
eases treated by bloodletting. Assuredly, the action of these 
two remedies is not the same; but patients died under both and 
recovered under both. And here it is that the public forms un- 
favourable judgments of physic and physicians. Yet if physi- 
cians can explain to them, that even such apparently opposed 
mean's may both be right, the true physician knows full well 
how often both are wrong in the hands which have not learned 
to make distinctions, any more than have the public which passes 
this very natural judgment on what it does not understand. 
The fault is, that parties and fashions divide on apparently op- 
posed questions, because it is easier to follow than to reason, 
and because the spirit of opposition is, itself, the sufficient rea- 
son to far too large a portion of mankind, in every thing. To 
ignorance, fashion and party are all in all. These remarks were 



CURE OP REMITTENT. 81 

unavoidable; since, on no one point in this subject is it possible 
to speak, without some investigation of opposing opinions; un- 
less indeed by adopting a system and deciding by it, as those 
decide who, having once settled what they consider a belief, 
find no difficulties in any thing. 

I must here commence by separating, in some measure, the 
treatment of the acute from the chronic remittent, or the sim- 
ple from the relapsing or habitual disease, since there are some 
important differences in the practice; while also I can but con- 
sider the acute one as it most generally appears in our own cli- 
mate. 

Can emetics cut short the disease, when given at the com- 
mencement of the attack; and if an emetic be given, is antimony 
preferable to ipecacuanha? Here is the first example of differ- 
ences in opinion; or rather, there are two points in dispute. 
The value of emetics given at the beginning of the fever has 
been too often decided on theoretical views, and consequently, 
as is usual in all such cases, exaggerated. Whoever shall judge 
of their power by his own experience, will probably not place 
much confidence on what, nevertheless, he will as probably re- 
sort to, if at least called on before it is too late. That they do 
occasionally terminate, or at least shorten the fever, must be ad- 
mitted; while they seem to be chiefly useful whenever the disor- 
der is attended by an increased action of the liver, or in that 
variety which, with us, goes by the name of bilious fever. 

They who consider, that, in this case, antimony exerts a use- 
ful action on the skin, with some who are willing to believe in 
some mysterious febrifuge power appertaining to this remedy, 
are of course strenuous defenders of the superiority of the eme- 
tic tartar; while among those who view the evacuation of the 
stomach as the great end to be obtained, ipecacuanha becomes 
the medicine. I must not undertake to decide: but it must be 
remembered that when the stomach is essentially disordered, 
when apparently it is affected by that very singular inflamma- 
tion which so often occurs in these fevers, it may be, and often 
is, the effect of antimonial emetics to augment that condition, 
and even to induce an irritability, as it is called, which often 
becomes of serious consequence in the progress of the disease. 
How often even death has been the result of such emetics, given 
improperly or pushed too far, is but too well known: and by 
such considerations probably, will a judicious physician be 
guided in his choice. That any peculiar advantage arises from 
so administering antimony for this purpose that it shall act also 
as a purgative, I cannot see, when this particular object can be 
attained by more manageable and less doubtful means. 

Presuming now that the disease is established, I need not en- 
large on the general treatment, commonly called the antiphlo- 

11 



82 CURE OF 

gistic regimen, since it is as familiar as it is admitted to be ne- 
cessary in all fevers; while a few of the circumstances which 
are esteemed to belong to this, or to regimen, must be inquired 
of shortly. I may proceed to inquire into the use and value of 
the other remedies which have been recommended and adopted, 

Respecting purgatives, not only at the commencement but 
through the progress of the fever, the general agreement is such, 
in our own country at least, that there can be no hesitation in 
recommending this class of remedies; at least in an English 
writer and physician. But it is a question demanding some de- 
tail. 

Universally, and through the whole disease, that a state of 
bowels approaching as nearly to the natural one as may be ? 
should be preserved, is a point on which there are not two opi- 
nions among ourselves; while the remedies required, various as 
they are, are too well known to need enumeration. One cau- 
tion only is necessary on this point: and it is, not to forget the 
distinction, too often neglected, between the medicines which 
evacuate the entire system, or the saline purgatives, and those., 
the resinous ones as they are called, including also rhubarb, 
senna, &c, which act chiefly or solely on the natural evacua- 
tions of these organs. There are often strong reasons for avoid- 
ing the production of debility; and where bloodletting is im- 
proper, the watery evacuation produced by the excess of saline 
purgatives is also injurious. They are, in fact, causes which 
frequently aggravate the disease, and very often bring on re- 
lapses: and I need not say that when the other class of purga- 
tives are so administered as to produce the same effects, the con- 
sequences are necessarily equally injurious in the same cases. 
Let this practice be viewed in its analogy or otherwise to blood- 
letting, and the physician cannot well be at a loss how to regu- 
late his medicines. 

If I have not yet named calomel in this class of remedies, let 
me premise that if I have hitherto considered our remittent fe- 
ver as it is when a simple disease, it is common and particularly 
in hot summers, for it to partake more or less of the character 
of the severer and complicated disorders of the hot climates, 
from derangements of the biliary system; forming that bilious 
fever, which is too often supposed to be a distinct disease: the 
additional symptoms, always sufficiently obvious, consisting in, 
or being founded upon an increased, and possibly, a further 
morbid, secretion of bile. 

It is in these cases that calomel is considered to be an almost 
necessary purgative, or at least to effect purposes less easily at- 
tained by other means; while with respect to its repetition, no 
rules can be given save that of its apparent necessity, as indi- 
cated by the symptoms, and of attention to the effects which it 



REMITTENT. 83 

produces. Here also I must remark, that the imaginary objects 
to be attained by emetics in these cases, are, by many physi- 
cians, thought to be better gained through this remedy; and fur- 
ther, that an early and effectual administration often mitigates 
or abbreviates a disease that might otherwise be severe and du- 
rable. That it has any other effects on our own native fever 
than such as are derived from its power over the biliary system, 
I cannot discover;, while I have no right to judge whether or 
not it exerts any different or mysterious action over the severer 
remittent of hot climates. 

I must however, while on this subject, make a remark on the 
use of calomel in the chronic and relapsing variety: but whe- 
ther it will be confirmed by others, cannot be known till the 
views which I have been attempting to promulgate respecting 
this disease shall have become more general. And when, as 
will be perceived in the course of this work, I am one of those 
physicians who consider that this medicine has been greatly 
abused, the remark w 7 ill probably command more confidence, 
as the result of experience opposing what may be almost viewed 
as a prejudice against this much misplaced remedy. 

This remark is, that in the relapsing disorder, even if the at- 
tack should occur at the end of winter, in patients free from all 
suspicion of deranged liver or biliary affections, and when not 
the slightest indications of these can be traced, and when, fur- 
ther, the relapse may be the twentieth or fortieth to that patient, 
the operation of calomel is to produce obvious effects, which, if 
I need not specify them, physicians know well to be those which 
never occur except under derangement of this secretion. And 
at the same time, what is the important point here, it will be 
found that after every such effect of the medicine, the force of 
the disease diminishes, and that whenever the natural secretions 
recur, that particular relapse is about to terminate. Hence 
therefore I am led to consider, that even where it is least sus- 
pected, and indeed not to be believed present, there is often, in 
the chronic relapses, a derangement of the biliary functions; 
and that calomel,, being the remedy for these, is apparently a 
remedy which cuts short or cures that relapse. That the bilia- 
ry derangement is here the cause of the febrile return, we have 
no right to say from this evidence; or that calomel, because it is 
the cure of this, is the cure of the disease. But be the theory 
what it may, the utility seems unquestionable: and till I find 
that other practitioners shall fail where I have succeeded, I am 
bound to point it out as a remedy, and among the primary or 
initiative ones; recommending also its cautious repetition just as 
long as it shall be found to produce the evacuation of morbid 
bile, while, from the moment this ceases, it becomes injuri- 
ous. 



S4 CURE OP 

With respect to sudorifics, we have, as on all else, contend- 
ing opinions; while it needs not be said how their supposed va- 
lue has been most commonly derived from a favourite theory 
rather than from observation. That sweating is often an at- 
tendant on the natural solution of a fever, is true, as the same 
act often terminates the paroxysm of the remittent or the inter- 
mittent. But after a hundred such solutions of paroxysms, 
these fevers do not the less return; though if artificial sweating 
can really be produced, it will often shorten the disagreeable or 
distressing portions of the whole which consist in the cold and 
hot stages. But when the critical solution or the termination 
of a fever is attended by sweating, it merely proves that a revo- 
lution has taken place in the deranged functions, of which this 
is the test and effect, not the cause: though it appears to be very- 
much from mistaken reasoning as to this fact, that the virtue of 
this class of remedies has been so much extolled. This much 
appears certain, that when it is difficult to produce this effect by 
remedies, it is because the disease is unconquered, and that 
when they do act, it is because that is about to yield; while that 
which is a coincidence is held to be the virtue of the remedy, 
And it is also familiar, that if we can succeed by the more pow- 
erful sudorifics, such as Dover's powder, in forcing this effect in 
an early stage of the disease, nothing seems gained by it, while 
it is often effectual when produced by milder means; a proof 
that the useful result is an index of a natural action, and not the 
effect of the remedy. Thus it is for the milder effects of a si- 
milar nature; a moist and soft skin succeeding to a harsh, hot, 
and dry one; marking a favourable change in the disease itself, 
and not being the produce of remedies, which, in reality, are 
commonly inadequate to any purpose. If Mindererus' spirit, 
or the acetate of ammonia, the vulgar remedy of ordinary prac- 
titioners, or saline draughts, or aught similar, amuses the pa- 
tient's anxiety, or serves to pass the time of expectation, they 
may usefully occupy the mind; and in this view they are at least 
innocent remedies. 

Yet even here, I would add one caution, and that is respect- 
ing the state of the stomach, often singularly affected; while it 
applies to all cases of amusing or placebo remedies, be the pur- 
pose of these to gratify a patient who cannot imagine the use of 
a physician who gives no medicine, or to make up that bill, or 
remuneration, which a most injudicious custom has agreed to 
give in no other manner. It is easy to observe, daily, in this 
disorder, that thus to tamper with the stomach, not only in- 
creases and protracts the paroxysms, but prolongs the whole 
disease, and that those cases, on the average, succeed far best, 
where the least of this injudicious and empirical interference 
takes place. 



REMITTENT. 85 

The use of opium requires also a few remarks, as it has been 
alternately lauded and condemned, chiefly from not attending 
to some very necessary distinctions. Generally, that it must 
be improper when, it is necessary to administer purgatives, 
would be a natural conclusion; yet even here it is often useful, 
by facilitating the action of these from its antispasmodic effects; 
as it further is, by removing that irritation, which is apt to fol- 
low their salutary action. 

As to its value in procuring sleep, though there may some- 
times be even a state of drowsiness approaching to coma, and 
pro tracted^ also long through the disease, it is more common to 
meet with sleeplessness, or disturbed, or irregular rest; while I 
have even seen this consequence carried to such a degree, that 
the patient did not procure above an hour's sleep out of the 
twenty-four, during the whole period of six weeks which the 
disease lasted. 

In all these cases, as long as the want of sleep is the produce 
of the febrile action, or attends the paroxysm, the use of opium 
serves but to increase the evil, as far as I have observed, or is 
productive of no advantage, at the best. But it does also hap- 
pen, that during the remission, there remains an excitement, 
more visible in the faculties of the mind than in the body, pre- 
venting sleep; a condition under which opium is often advan- 
tageous, by procuring that rest which would not have come on 
till the new paroxysm was again ready to break it up. Thus 
also, as might be anticipated, it is more applicable towards the 
end than the commencement of the fever. With respect to its 
power as a stimulant remedy, whatever that be, its utility and 
application will be judged and guided by the same rules which 
regulate the use of wine. 

If I place here that which relates to food, (not its usual situa- 
tion in medical writings) it is because of a connexion which the 
rules respecting it have with the immediately preceding remarks; 
and if I formerly noticed this subject, it is still necessary to re- 
cur to it here, in somewhat more detail. 

It is a common error in all fevers, to administer food fre- 
quently and in small quantities, under popular and theoretical 
notions respecting the powers of the stomach. To pass by what 
does not relate immediately to the present subject, this is fre- 
quently a very injurious practice in the remittent fever, even 
when Hs character is mildest. Even though there should not be 
a repugnance to food, the process of digestion is suspended, or at 
least deranged; and the consequence is, not simply that the food 
thus given is useless, and not merely also that it produces sensi- 
ble inconveniences, but that its effect is to prolong the parox- 
ysm, or to render it more severe, or, in some cases, to destroy 
the interval altogether, and to render the fever continuous. 



S6 CURE OF 

Both as to medicines and food, the stomach cannot here be trifled 
with or deranged with impunity: and so true is this, that even 
in the most mild and chronic remittent, as was formerly re- 
marked, the same bad effects, namely, increase of severity, or 
the protraction of the paroxysms, is a frequent consequence of 
the injudicious use of food. There is but one period in which 
it can ever be given with safety, and that is, the interval, or re- 
mission; and, as I formerly noticed, the choice should fall on 
the commencement of that, while in the severer cases, where 
the distinction between the paroxysms is most imperfect, it is 
for the physician to watch the time when the least evil is likely 
to accrue, keeping in his mind these general principles. 

And further, as, in many cases, this is a disease of debility, 
as it is indeed in all, after the commencement, it is plain that 
food, as far a-s the stomach can manage it, is even an important 
remedy. As to the choice, that must necessarily be guided by 
trial and by present circumstances, of which the attendant must 
judge; remembering, however, that there is no greater, and no 
more common error, than that which imagines insipid articles 
of diet, such as fish, chicken, and all the rest of the farrago, 
whether vegetable or animal, usually recommended to sick per- 
sons and convalescents, to be the most digestible, or, as it is 
termed, the most light. The truth is as much the reverse as it- 
can well be; while in general, the fancies or desires of the pa- 
tient are the best guides which the physician can follow; though 
he will distinguish those conditions where stimulating food 
would be improper, remembering that this also is really that 
which is the most digestible. 

It would be well if we could avoid believing, that not mere- 
ly on this point, but in much more that relates to the manage- 
ment of the sick, that ascetic principle which, often unsuspected, 
never acknowledged, intrudes itself so perpetually into all our 
opinions and conduct, marring, by habit, that happiness which 
it once opposed from principle, and multiplying the miseries of 
which there is surely no want, did not also intrude itself intc 
the direction of sickness, rendering more oppressive its inhe- 
rent evils. But there is much of this control, and many of 
these follies, which an acute observer will easily trace to that 
principle; the humane principle which has determined that what- 
ever we wish for most and like best, is precisely that which is 
most injurious, and in which we must be controlled: a rule that 
gains its full and pernicious sway, when it is aided by that inhe- 
rent principle of tyranny and love of command which enjoy 
their full scope over the helpless bed of sickness. 

I cannot avoid here naming the external application of cold, 
of cold water; or, under modifications of the state of the dis- 
ease, of the tepid bath. How much it has been praised by Jack- 



HEMITTENT, 8 i 

son, Currie, and others, is well known to all medical readers, 
as are the cautions which relate to its use. That the chief be- 
nefits derived from it, have also occurred in hot climates, I need 
not say: while I shall refer to the authors whom I have named, 
for information and opinions which I could not well discuss here, 
and which are not rigidly necessary; inasmuch as it is a prac- 
tice little resorted to in the fevers of this character in our own 
country, and perhaps not very often applicable or necessary. 

I must now return to medicines, and to the use of tonics, as 
they are called; reserving to the last the two more disputed 
questions which relate to the use of wine and to that of blood- 
letting. 

If the use of bark, which may here stand as the representa- 
tive of all the tonics, as it is that especially adopted, has been 
condemned by numerous and enlightened physicians in the pro- 
per remittent fever, there are not wanting as many who place 
confidence in it; guided sometimes by experience, and at others 
by habit, or by theories: just as is true of those who oppose its 
use. It is a complicated question; since, like every other one 
in this disorder, its utility or disadvantages will partly depend 
on the individual characters of cases, as of epidemics; not un- 
frequently on peculiarities in the patient himself, and on a va- 
riety of collateral circumstances as tedious to detail as they 
must be superfluous to medical readers. Without doubt, there 
are instances where, even though no inflammatory condition is 
present, it does not cure the disease, but aggravates, not mere- 
ly the paroxysms but the entire disorder; whether, however, 
by any greater action than that of deranging and oppressing the 
stomach, appears uncertain. Even thus it may be pernicious: 
but I see no evidence of a very common opinion in physic, that, 
thus given, it is the cause of the glandular visceral diseases so 
common in these fevers, or so commonly following them. 
These occur equally where bark has not been given; they are 
often in existence even before the fever, and appear in many 
cases to be quite independent of it; while, ignorant as we are 
of their immediate causes or nature, we have no right to assume 
that they could be the result of a remedy with whose actions 
also we are equally unacquainted. This is one of the inconse- 
quential and gratuitous conclusions in which physic abounds but 
too much; but it is one that is examined by evidence elsewhere, 
and on which I need not therefore now dwell. 

The leading objection to the adoption of bark in this fever, 
is, however, derived from the presence of what is called in- 
flammatory action, consisting in a high state of pulse and so 
forth, and very particularly from the presence of topical in- 
flammation: and it is in these latter cases that it is so violently 
condemned by French physicians. Yet even here, opinions 



88 CURE OF 

are divided; and it has often actually been found to be the re- 
medy in such cases. It is as painful to a writer to leave his 
readers in suspense on points so essential, as it would be pre- 
sumptuous to decide; yet it may be suggested that if, as will 
hereafter appear, the inflammatory affections of remittent are of 
a peculiar character, and not proper phlegmasia?, and if certain 
visible and demonstrable ones are actually cured by this reme- 
dy, and aggravated by evacuants, the question will not impro- 
bably be decided in favour of those who recommend it in all 
cases; and it may not be difficult then to discover that prejudice 
or incorrect observation will explain that testimony against it 
which has been thought to be derived from experience. 

The utility of bark or of tonics in general is, however, scarce- 
ly disputed in those cases where the symptoms are those of de- 
bility; and still more where they are what are called malignant; 
nor, in the advanced stages, of a disease of this nature, even 
should the fever be almost continuous, or with imperfect remis- 
sions. Still less is it questioned when the length of the inter- 
vals and the perfections of the remissions have brought this dis- 
ease into the congenerous class of intermittent fevers. As soon 
as that character is at all formed, this remedy may be used, and 
even by those who object to its general use, with the caution 
that it is not urged beyond the remission or intermission, if in- 
deed that be necessary; and thus it often terminates at once a 
disorder, that might pass into a troublesome or chronic inter- 
mittent. For all else that belongs to its use, I may refer to 
the treatment of intermittents, hereafter discussed. 

It is with some hesitation that I enter on the question of wine ? 
disputed as it has been, and under the revolutions which its use 
in this disease has undergone. It is, perhaps, impossible to find 
a just medium between opposing opinions; but it is, at any rate, 
possible to state a few doubts and queries as to this subject, on 
which others may reflect, and, perhaps, arrive at some conclu- 
sion. 

Theoretically, wine is held to be injurious, because it excites 
the action of the heart, and increases the tendency to inflamma- 
tion, and because this disease is held to be of an inflammatory 
character. There are here two points involved; and, to prove 
that wine must be injurious, it is necessary that both should be 
established. The question of experience forms a separate subject 
of consideration. 

It may appear a very extraordinary doubt to suggest, against 
the almost uniform and continued opinion of physicians; but is 
it proved that wine increases inflammation, when existing, or 
produces the tendency to it in healthy subjects or in diseased 
ones? Will those who believe it ask themselves why they do 
&% and whether it is ;._■ le of the hereditary opinions of phy- 



REMITTENT. 89 

sic, established, no one knows why, and followed because it has 
been followed? But, granting that there are cases of inflam- 
mation, or a species of inflammation which wine would increase, 
physicians know full well that they are utterly ignorant of the 
real distinctions among inflammations which, to the sense or the 
eye, may appear the same; and that while there are some kinds 
or varieties which are to be cured by stimulants both local and 
general, as I shall hereafter show very fully, so are there in- 
flammations, and apparently inflammatory states of the entire 
system with increase of circulation, where wine is a remedy in- 
stead of being injurious. Nor does it appear that the habitual 
use of wine produces a tendency to inflammation in healthy sub- 
jects; since it is notorious that among water-drinkers, the dis- 
eases of active inflammation are most frequent, and require the 
most energetic treatment. 

But this whole question is too long to be indulged in here; 
and I may therefore ask, in the next place, whether it is proved 
that the general accelerated state of the circulation in the remit- 
tent fever is an inflammatory condition, and whether the topi- 
cal affections are of a nature to be augmented by wine. This 
question, however, is particularly involved in the inquiry re- 
specting blood-letting; and I must therefore suspend it till I 
have examined into this practice, when it will admit of a more 
decided answer. 

Here, also, I must avoid the question of the fevers of hot 
climates, or submit my belief to the experience of those who 
hold forth blood-letting as the only remedy in this disease, or at 
least as a most efficacious one. I am, however, inclined to be- 
lieve that, if there are fevers of this nature with severe topical 
affection, in which blood-letting, in the hands of good observers, 
has been found a cure or a source of repeated and unquestiona- 
ble relief to these affections, while the disorder has at the same 
time terminated in health, such affections have been of that in- 
flammatory nature which blood-letting is known to relieve, and 
that it has here, of course, been a judicious practice. And fur- 
ther, if, without topical affections, blood-letting does truly cure 
the remittent fever in any situation, then must its utility be ne- 
cessarily granted: though I must here make a reservation re- 
specting probable differences in the essential character of this 
disease in different climates, seasons, or instances, from causes 
assuredly very little known to us at present. 

And this I believe to be the fact; and that all the discordances of 
practice and opinion have arisen from that fault, far too universal 
in physic, of judging diseases by their names, or concluding that 
the definition of a nosology or the general rules of a systematic 
writer, are applicable to every case. And if there are cases in 
which this practice is injurious or destructive, as is on the other 

12 



90 cure or 

hand most certain, then is it most essential that physicians should 
cease to be guided by a universal rule, or, as is truly the case, 
by the predominant opinion of the day. 

On this subject, I can but state my own experience and the 
opinion derived from it, leaving it to others to confirm or con- 
tradict that by their own observations; while, should it even be 
an imperfectly founded one, it will have the good tendency of 
causing those to inquire into the cases before them, who have 
hitherto been blindly following the rules laid down for them by 
others. 

That opinion is, that in the far greater number of cases oc- 
curring in our own country, the practice of blood-letting is most 
commonly nugatory or superfluous, or else injurious. But I 
must enter into some details on this subject. 

In the first attack of the fever, and often through many suc- 
cessive diurnal periods, the pulse is hurried, contracted, hard, 
or full; or the general appearance, to a common careless ob- 
server, is that of a state of circulation similar to what takes 
place in inflammatory affections. This state however is, when 
accurately viewed, the commencement or the first portion of the 
paroxysm, and its analogy is found in the similar state of circu- 
lation occurring in the first stage or stages of the intermittent 
paroxysm. And if it proves durable through any one diurnal 
period, or durable as it relates to the whole disease, it merely 
marks that condition of the paroxysm and of its returns, which 
equally occurs in certain cases of the pure intermittent. In 
other instances, it will be found that the duration of this state 
of the circulation is brief; or it subsides without the interference 
of the practitioner, as the paroxysm itself proceeds towards re- 
mission. 

This fact and this analogy ought to explain what the real na- 
ture of this particular condition in the remittent is; and if it is 
so generally mistaken for an inflammatory state, perhaps the 
term inflammatory fever, and the apparently groundless erection 
of a disease of this character by nosologists, has aided in esta- 
blishing an opinion which must however be chiefly traced to 
that servility of routine by which the unthinking mass follows 
the road which a predominant theory or a prevailing fashion 
points out to them as the easy one: since, of this quality, must 
the mass be every where. 

Further, it may happen that there is also present some topical 
symptom, such for example as headach, the most common of 
all. How often headach is the result of conditions the most op- 
posed to local inflammation or inflammatory action, I surely 
need not say; but if, in the case under review, it exists with this 
particular state of the circulation, it is easy to see how, under 
the previous theory or prejudice, it will be conceived to depend 



REMITTENT. 91 

on a fixed topical affection of the brain. Thus also is a casual 
catarrh, not an unusual accident in this disease, attributed, un- 
der the same prejudice, to inflammatory action in the lungs; and 
thus even does it occur frequently, that such a combination is 
actually mistaken for pleurisy or peripneumony. The same 
reasoning applies to other topical affections, and I need not there- 
fore dwell on it; besides which, as I have already suggested in 
speaking of bark, and shall hereafter explain more distinctly, 
the predominant, I do not say the whole of the topical inflam- 
matory affections in this disease, are of a peculiar character, and 
not true phlegmasia^. And, if I wished for a very high autho- 
rity of a somewhat distant date on this point, as I have, in 
speaking of intermittent, alluded to many modern ones, I would 
refer to Lobb, who decidedly rejects blood-letting in fevers of 
this nature, however violent and inflammatory the symptoms; 
and even in the cases where acute pleurisy or rheumatism are 
present, or in the diseases so often considered as pure pleurisy 
and pure acute rheumatism. It is not, however, for me to deny 
that real inflammations requiring the lancet, may exist or have 
existed in recorded cases that have not come under my own re- 
cognisance. 

It is easy therefore to see the causes which, united to a preju- 
dice, or in hands governed by a routine, lead to that which I 
here consider an erroneous judgment; and I may now inquire 
what the effects of blood-letting really are; since, although in the 
majority of cases, it is, as commonly practised, injurious, as 
there are others in which it is without important effects of any 
kind, there are a few in which, under restrictions, it appears be- 
neficial. 

In a robust patient, at the first attack of the disease, and when 
the fever is the first of its kind to that patient, blood-letting is 
often useful, and at least not injurious. Its good effect is that 
of reducing that activity of the circulating system, or that vi- 
gour generally, which renders the first portion of the paroxysm 
correspondently energetic; thus moderating the whole result, 
not only of the first, but also of the subsequent paroxysms, and 
consequently of the total disease. And to judge respecting the 
propriety of its repetition, we must be guided by the same rules: 
a consideration of the constitution and character of the patient, 
and further, not merely of the appearance of the disease in that 
patient, but of the prevailing character which the endemic of 
that particular season may possess: as it is most certain that in 
different seasons, the remittent does vary most essentially in its 
character. 

And here it is that watchfulness is required; since that reme- 
dy which commenced by being beneficial, may become, in its 
repetitions, not simply superfluous, but injurious, and even fatal. 






i#£ CURE OF 

It is by no means uncommon to find, that immediately after a 
blood-letting which even appeared to be justified by the symp- 
toms, sudden debility follows, or the whole character of the dis- 
order is changed to one the very reverse of what it appeared to 
be originally; often causing the physician to repent of his judg- 
ment or his haste. Yet even here, the routine practitioner often 
continues to follow that which custom has laid down as the re- 
medy, while even the more cautious one is sometimes induced 
to persist in a pernicious practice, misguided by the topical af- 
fections; or else, by casually arriving at that period of the pa- 
roxysm, when the circulation tends to re-excitement, is misled 
into wrong, when more care, or more frequent visits, would 
have led to a different system or a different judgment. I know 
not that I need dwell longer on what ought to be sufficient to 
furnish the grounds for decision in this case; but I must further 
add, that it is an occasionally beneficial effect of blood-letting to 
convert the almost continuous fever into a decided remittent, or 
to produce, still further, perfect intermissions: an effect some- 
times also occurring in the analogous case of intermittent, un- 
der the form of a change of type. 

It is perhaps a more common fact in our own country, as I 
have already hinted, for blood-letting to be nugatory in this fever ? 
or to produce no effects either good or bad; though I must limit 
this result to the cases in which the remedy is applied but once, 
or perhaps twice. When rashly repeated, as is but too common 
under the erroneous views just noticed, it rarely fails to be highly 
injurious, or even fatal. In using the terms nugatory or super- 
fluous, I must, however, explain them by saying, that the con- 
dition, in the first place, which it is applied to remove, is that 
state of the circulation which would equally have subsided in 
the progress of the paroxysm, and have continued to return 
with gradually diminishing energy through the course of the 
disease; the remedy appearing to have produced an effect which 
would equally have occurred without it: while if no injurious 
results follow, it is because of the existence of a disease natu- 
rally mild, or of a constitution correspondently fitted to bear 
with impunity what, in another case, would have been inju- 
rious. 

The cases in which this remedy is likely to be injurious, whe- 
ther in one application or in its repetitions, may now be easily 
judged of, a priori, by attention to the preceding remarks; 
while, in practice, the consequences of its use, when bad, ought 
not to be obscure to any practitioner of almost the most common 
discernment; if at least he is one who is accustomed to reason 
for himself from his own observation of the individual cases be- 
fore him. What those evil consequences are, I need not point 
out in detail; as thev are those which conduct to a very pro- 



REMITTENT. 93 

tracted case, with long-continued debility, injury to the intel- 
lect, or affections, general or topical, almost incurable; or else 
to a fatal termination, marked by the previous sinking of the 
vital powers, and by all those symptoms, so often attributed in 
these cases to dangerous or fatal typhus, as they also occur in 
that kind of fever. 

That these are very common events in this fever, from such 
errors and from such misapplied practice, it will require but lit- 
tle of original observation and reasoning to see, every where 
and in every season; and were I to pronounce respecting an ave- 
rage, from my own experience, it: would be, that, in England 
generally, the evil consequences arising from misapplied blood- 
letting very far exceeded the good, and further, that it was the 
most common cause of fatal terminations or ruined health. I 
shall hereafter have occasion to show more particularly how it 
acts with respect to the cases combined with local nervous af- 
fections; as this must form a separate subject in the present 
essay. 

Were I indeed to indulge in that violence of generalization 
so usual with physicians, and so much too prevalent among those 
who undertake to point out or review a system of practice, it 
would be to assert that it were better that blood-letting should be 
utterly abolished in this fever, than that it should hold a place 
so egregiously abused. But while such sweeping judgments are 
too often the produce of temper or arrogance, as well as of op- 
posed prejudice, they are as ill suited to physic, in all the 
branches of this most complicated department of natural history, 
as they are unworthy of philosophy and opposed to humanity. 
Let he who writes on physic never forget that his opinions in- 
volve human life and happiness both; and that to gain a victory 
of opinions will afford small gratification to him who reflects 
that he has gained that at the expense of even one life. 

As I need not protract the remarks on this subject, I may 
now return to the question of wine, unfortunately also, too of- 
ten made a question of fashion and temper, rather than of ra- 
tional and sober inquiry. 

If this remedy has been misapplied in the remittent fever, it 
cannot now be very difficult to see the cases in which it might 
be concluded injurious; since they should be those, from theory, 
in which blood-letting is beneficial. Thus would it be avoided 
in the commencement, especially, of a disease attended with 
great affection of the circulation, in patients of robust and vigo- 
rous habits, in seasons of peculiar endemics, and incases where 
there may be suspicion respecting the exact nature of the topi- 
cal affections which may chance to be present. And while in 
such a disease and in such stages of it, no peculiar benefit could 
be expected from wine, even should it prove innoxious, it is al- 



94 CUKE OF 

ways safe at least to avoid its use, even though the character 
which it possesses of augmenting such a state of circulation 
should be a false one. 

Reversely, its use is pointed out in the opposed circumstances; 
and that it is a remedy of value 1 can entertain no doubt, though 
assuredly far from the specific or powerful one which it was 
thought not many years since. That its singular combination 
of stimulant and sedative powers renders it one of the most 
convenient of the remedies generally classed under the vague 
term of tonics, seems to have been established by experience 
that can hardly be disputed; and the most determined theorist 
can scarcely deny to himself, that he has gained decided advan- 
tages from its use in the low or later stages of fever, and that it 
has often appeared to him the means of at least supporting the 
patient to a favourable termination. As to the minute details of 
its application, or of the obvious substitutes, it would be quite 
superfluous to enter on them. He who cannot act in physic 
without definite rules, is not fit to conduct it; and to lay down 
such directions, is mostgeneraliy to produce more evil than good 7 
by putting tools into hands unable to apply them or to decide on 
the propriety of their application. 

Such is the leading catalogue of the general remedies in re- 
mitting fever. I have said nothing of the use of mercury as a 
remedy acting on the general system; preferring a reference to 
authors on a subject which I do not profess to understand and 
on which I also doubt. 

I gladly leave this question to those who may possess more 
knowledge of it than myself, to offer the last remarks which I 
have to make, and which relate to the rigidly topical remedies. 

These may be reduced to local blood-letting, blisters, and the 
local application of cold. It does appear that the former some- 
times relieves the affections of the head in particular, while even 
in case of erroneous application, no great inconvenience can be 
apprehended from it, unless pushed to excess or repeated too 
often. It cannot be very necessary to give minute directions 
on this subject; since the general principles already explained 
are equally applicable to it: while, in as far as deceptive good 
effects, leading to ultimate injury may follow, I shall have occa- 
sion to explain these in a future part of this work, to which I 
shall now therefore refer. Let the practitioner keep in view, 
that in very many cases of this nature, there are apparent good 
effects which do immediately follow the use of this remedy, but 
that these are shortly succeeded by bad ones; and that even lo- 
cal blood-letting, whether through cupping or leeches, may be 
so abused as to produce the same injuries as general bleeding. 
Let him also recollect, that this state, which is conceived to be 
an inflammatory condition of the brain, is often of a very dif- 



REMITTENT. 93 

ferent nature, as I shall show hereafter; that pain in the head, 
presumed, under a false theory, to be within the scull, and de- 
pendent on disorder in the brain or its membranes, is very fre- 
quently external; and moreover that it is very often a merely 
nervous disease, analogous to Neuralgia, not to be removed by 
local blood-letting, but aggravated by it; and lastly, that even 
when absolute inflammation is visibly present, as in the ophthal- 
mia of this character, it is an inflammation which is augmented 
by blood-letting, as I shall prove distinctly hereafter. And be- 
fore I quit this subject of the cure of remittent fevers of what- 
ever variety, let me say once for all, that the reader must not 
condemn it as superficially detailed, nor attempt to apply it till 
he has read through the whole work. Had I attempted to ren- 
der it complete, it would have been to anticipate much for which 
he is not yet prepared, from the want of facts and evidences 
that belong to a later part of these inquiries: while I must also 
have made many repetitions, in saying here what it will be 
much more necessary as well as more useful to say in a future 
place. 

With respect to the local application of cold, its effect is 
sometimes to relieve such pains; and this is a remedy from which 
no evil that I know of can follow, under any misplacement of 
its use or extravagance of application. Of blistering, I cannot 
speak in the same favourable terms; as far at least as my own 
experience goes: believing that while it rarely produces any 
marked good effects, it is very seldom without vexatious re- 
sults to the patient, by producing an irritation, and an absolute 
increase of all the febrile symptoms, or at least of symptoms 
which materially aggravate the sufferings arising from those. 
They who imagine that a blister is merely the local application 
which it seems to be, must be very incurious observers, to say 
no less; since be the cause what it may, whether the poison of 
the cantharides is absorbed into the system or not, there is an 
effect, and often of considerable duration, produced, which does 
not result from a vesication of the same extent excited by other 
means. 

Yet I know and feel that while I thus decide, I may possibly 
be very wrong, differing as I do from many physicians to whom 
blisters have appeared a most valuable remedy. Yet it is my 
duty as writing from observation, and not compiling opinions, 
to state the results of that observation: while I am willing to 
believe that others may conscientiously have taken the reverse 
view, and also under greater opportunity for observation, as 
well as greater capacity than my own. And this may be ex- 
plained as to both the opinions, opposing each other as they do. 
by that fact which I have here alluded to so often; namely, that 
the characters of fevers, whether as single cases or epidemics. 



.96 CURE OF 

are extremely various, and often demand remedies as different; 
so that, after all, it must, as on so many other points, remain 
for the judgment of the physician himself, in each case, to de- 
cide either for or against this remedy, by observation on his 
own practice, and by knowledge, or trials, of the particular 
epidemic or fever which it may be his lot to treat. This, how- 
ever, I would still remark as to the remedy in question, as I 
might of so many more all through physic; that a fancy or pre- 
judice is not less often the cause of a favourable judgment, than 
it is the inducement to adoption, when the experience itself is 
of no value: while I have had abundant proofs of this by wit- 
nessing, in a hospital practice of great extent, and through a 
long course of years, the invariable use of blisters in these cases 
by one physician, and the as invariable neglect of them by the 
other, in equal attendance; when the results, as proved by the 
registers, were absolutely equal for both, during the whole pe- 
riod. 

Such are the views relating to the treatment of well-marked 
remittent; but I must now add some remarks respecting those 
milder varieties which I have described at so much length; a 
length for which I should apologize had I considered that sub- 
ject understood as it ought to be. 

A sweeping conclusion as to the ordinary simple fever of this 
character, would be, that it requires no remedies at all; and 
most assuredly, it is far better left to its own operations, or to 
nature, as the phrase is, than that it should be tampered with by 
intermeddling and routine practitioners. There is little good 
to be done by remedies; but it is not so as to the harm. Left to 
itself, its periods proceed in a very orderly manner to a favoura- 
ble conclusion; but it is rarely so when a busy or active practice 
interferes. What the evils to be produced may be, can so ea- 
sily be concluded from the preceding remarks, that I need not 
detail them. 

When however I say that it is best left to its own progress, 
this is a remark which merely excludes active practice or decided 
remedies. Here, as every where, we cannot dispense with the 
removal of all causes of offence and irritation; or with what 
may be called negative practice, by means of repose, tranquillity, 
the removal of thirst, and so forth. 

And if, in the description of these varieties, I was obliged to 
notice the evils produced by exertion, I cannot here dispense 
with some further remarks on that subject: since the paroxysms 
are thus frequently prolonged or aggravated, when, by more 
care and attention, they might have produced comparatively 
little inconvenience: an occurrence also more common, for ob- 
vious reasons, in the slighter and chronic cases than in the bet- 
ter marked u nervous fever." 






REMITTENT. 97 

Thus when the whole visible paroxysm is nothing but a mus- 
cular debility which, with care and rest, would have been li- 
mited to a few hours, an exertion through that time will not 
only protract it through a considerable interval, but also pro- 
duce other symptoms and greater inconveniences: such as, in- 
crease of pulse, headach, additional loss of appetite, and an aug- 
mented sense of general suffering. The same consequences also 
follow from mental exertion under the same circumstances; and 
if I need not repeat what I formerly said respecting sleep, it is 
plain that the reasoning is the same. In all these cases, that in- 
dulgence to the feelings or caprices of the patient which huma- 
nity ought to dictate, is also correct medical practice; much too 
often, however, controlled by the ascetic principle on one side, 
and by that of what, for want of a better term, I may call ty- 
ranny on the other. 

Perhaps, under the head of negative rather than positive prac- 
tice, I may include that attention to the bowels which consists 
rather in maintaining a natural condition thana system of purging; 
though, here, there are modified cases, where real purgatives, 
and among them calomel, will be necessary; while that necessi- 
ty must generally be left to the judgment of the practitioner, as 
definite rules for it in all cases, cannot be laid down. This was 
a subject, however, which I took occasion to discuss at some 
length when treating of the severer fever of this nature; so that 
I may here refer the reader to what was most conveniently ex- 
amined then. And as an attention to the action and state of the 
stomach and bowels is in reality nearly all that is required, in 
the majority of cases, while that also is indispensable, so is it 
requisite that the administration of food should be regulated 
strictly by the rules which were formerly pointed out. In this 
moderate fever also, if wine is not absolutely necessary, it is 
always convenient or useful, as it is almost invariably safe, and 
not less agreeable to the patient, for whom, as in every fever, 
attention to the feelings and comfort is essential; an attention 
which, whether it concerns the mind in one way or in another, 
is far too often overlooked or neglected in all diseases, either 
from negligence or want of active humanity, or from that cal- 
lousness of sympathy which is too common in those who know 
not by experience what disease and ill health is, or in whom it 
has been worn out by use or by multiplicity of practice; that 
feeling of trade it may be called, which forgets the fellow-crea- 
ture in the routine of business. 

There is a state however in this variety, most commonly en- 
tirely overlooked, where positive medicines are useful; while by 
an accidental coincidence rather than design, they are often 
blindly given in reality, if less effectually than they might be: 
the practitioner himself doing the good which he did not intend. 

13 



yS CURE OF 

It is by no means unusual, as I remarked before, for it to sub- 
side into an intermittent, while the paroxysms are so slight and 
so indefinite as not to attract the attention of the routine prac- 
titioner, who sees in the debility which attends this state, no- 
thing but what is termed convalescence: a convalescence how- 
ever which is apt to be a very durable disease, and not unfre- 
quently to subside into a long-continued train of local affec- 
tions, and even into the chronic or relapsing remittent or inter- 
mittent. 

An observing physician will however easily trace this termi- 
nation, even though there should be no symptom but a persist- 
ing and unaccountable debility; as be will find that it is parox- 
ysmal, and further, that it is accompanied by some symptom or 
other, in the shape of headach, affections of the appetite, or of 
the sleep, or even of the state of the pulse, at certain periods, 
which indicates an intermittent fever, however gentle or ob- 
scure. Here it is that bark, or perhaps arsenic, becomes an ac- 
tive and useful remedy; sometimes terminating, even in a day 
or two, a series of teasing symptoms, or a condition of dubious 
convalescence, or a better-marked disorder, which might other- 
wise prove what I have just remarked, and which, while it is 
exceedingly common, is very often a subject of much wonder, 
and also of not a little error, as well to the patient as to the un- 
observing practitioner. 

And in these casp,s it also is, that a similar and sometimes sud- 
den cure is produced by change of habits, or by change of air 
as it is called; while the action of this particular remedy is, as 
might be anticipated, most conspicuous in those cases where the 
residence of the patient is in a situation subject to the influence 
of Malaria, and while also, and chiefly in these cases, this pro- 
ceeding succeeds when tonic medicines fail; just as happens in 
chronic intermittents of whatever origin. And if I have just 
remarked that this condition is often cured by practitioners, 
blundering practitioners I may really call them, who are una- 
ware of its nature, that is the consequence of a routine practice 
which, whether for the purpose of swelling a bill of charges, 
or from some vague notions of giving strength by tonic reme- 
dies, furnishes the patient with a specified number and course of 
"bark draughts." In fact, it will be found, if I mistake not, 
a much more common occurrence in physic than it is suspected, 
that while the notion of producing strength by tonic remedies, 
and above all by bark, is one of those vulgar opinions where 
one term is set in hostility to another term, not the action of a 
remedy on the body opposed to the action of a disease on it, 
the most frequent success of such " strengthening" remedies in 
removing weakness, is, in reality, the power, whatever it be, 
which they exert over the obscurer intermittent affections. 



REMITTENT. 99 

I will not however terminate these remarks, without adducing 
the fact which I have now stated, namely, that of the intermit- 
tent and obscure fever which so often follows the apparently 
simple continuous or slightly remitting fevers, as an argument 
to prove further, or to confirm what I formerly stated, namely, 
that the fevers of this class, be their character and duration 
what they may, are real remitting fevers and the produce of 
Malaria. 

And if I consider this argument or fact as one of considera- 
ble weight in the general one which attempts to prove that the 
ordinary fevers, so commonly, or rather universally, attributed 
to speculative or imaginary causes, owe their origin to Malaria, 
I have reserved it to this place, partly for the sake of continuing 
the impression which I desire to make, and partly because thus 
placed in union with the other circumstances to which it belongs, 
its value might be more apparent. The fact generally stated, 
but still more particularly explained, as it. occurs in practice, is 
this; that whatever may have been the character of a common 
fever, a fever which is not marked, and certain, or a proved 
and admitted, remittent or marsh fever, or a fever which, in the 
essay on Malaria, I have supposed or granted to belong to a 
third class, its very common termination is to disappear by first 
assuming a perfect intermittent type. If practitioners do not 
remark, or authors and bookmakers have not distinguished, this 
very common fact, it is incumbent on themselves to explain the 
reasons: but if the former have not so done, these reasons will 
possibly be tolerably apparent in the manner in which " busi- 
ness" is conducted, while, for the far greater part, authors are 
systematic writers who do not concern themselves so far, or who 
from some other causes which can be imagined or assigned by 
those who choose to meditate on such matters, too often omit 
what requires investigation, research, or original thinking. 

And if this particular fact, or the subsidence of a continuous 
fever to health through the intervention of an intermittent type, 
occurs very commonly in even the minor fevers, be their dura- 
tion but a few days, or even one or two, then will it become 
additionally probable that even these fevers, be their technical . 
names, or their imaginary causes, what they may, are depen- 
dent on the same cause as that which produces intermittents, or 
that they are true marsh or remittent fevers; since this is one of 
the essential and remarkable characters of remittent fever in its 
most unquestioned form. And if this particular mode of ter- 
mination or evanescence never occurs in the fevers of contagion, 
or in the true typhus, which, from all my reading and observa- 
tion is the fact, then is it at least proved, or rendered highly 
probable, that these minor fevers do not belong to typhus, how- 



100 CURE OF 

ever physicians may still determine to persist in referring them 
to the several doubtful or imaginary causes formerly discussed. 
Such is an argument which will be satisfactory, however, 
only if it be admitted that intermittent is a disease produced by 
Malaria alone; since I must not mislead myself or my reader in 
a manner too common, by omitting views that would defeat the 
force of the argument. But on this subject, all that can be said 
has been stated on different occasions elsewhere, or may be de- 
duced from the general bearing of this essay throughout; and it 
is, briefly, that while Malaria has been proved to be a cause, 
and the common cause, of intermittent fever at least, no other 
cause of this disorder as an original one has been proved; and 
that rvhile it is unphilosophical to assume superfluous caqses, 
there are abundant proofs of various fallacies, as well as of a 
usual or prevailing laxity of language, or of what is called rea- 
soning, in physic, which are capable of leading, and have led 
to that popular belief which I here conceive to be an erroneous 
one. 

And let me make a general remark here, which is, that be- 
cause physic has been accustomed to proceed in defiance of all 
the rules of philosophy, persisting in those processes, common- 
ly called reasoning, which it had inherited, as it has continued, 
from the days in which all philosophy was of the same charac- 
ter, always professing to follow a better system, yet never act- 
ing on it, it seems, even to this day, to have indulged its indo- 
lence in believing that it was not amenable to the rules of phi- 
losophizing, and has chosen, very perseveringly, and not less 
conveniently, to suppose that its obscurities were insurmounta- 
ble, and that it might go on for ever, trifling with impunity, an 
exception to all other science; authorized to assert instead of 
proving, to dogmatize instead of investigating, and to imagine 
instead of observing. 

If now the fact be as 1 have thus stated it, and as appears to 
be the truth in our present state of knowledge, then may remit- 
tent fever be not merely a fever of the slenderest nature, but 
limited to a duration as brief as two or three days; as I formerly 
suggested: being thus the commonly reputed inflammatory fe- 
ver of the people, or the synocha of systematic writers and no- 
sologists. In this very fever, it will be often observed that the 
termination is in an intermittent, slender perhaps and brief as 
the original disease; terminated, itself, either by the remedies 
adopted, or, as appears equally common, by the mere fact of 
leaving the house and confinement for the open air: a change si- 
milar to that greater " change of air" which so often cures the 
better-marked intermittent. Nor, from previous reasoning, is 
there any cause why this should not be true of remittent; since 



REMITTENT. 101 

a perfect intermittent of the most marked character is often 
similarly cured after two or three paroxysms, or even after one. 
If this view of the frequent terminations of fevers in an in- 
termittent of this slight and neglected character, throws doubts on 
the distinct nature of the synocha of Cullen. so will it confirm 
those doubts which I formerly stated respecting his synochus as 
being always a mode of typhus; while, independently of all 
former reasons for that judgment, an immense proportion of the 
severer fevers, commonly called typhus and reputed contagious, 
must be taken out of this list and placed in that genus to which 
they justly belong. This really is a serious subject, not sim- 
ply on account of the wrong practice to which it leads, but of 
the useless and troublesome precautions so often adopted from 
mistaken notions of contagion, from the alarm thus produced, 
and from the neglect of patients to which that alarm so often 
gives rise. Let it not be supposed however that I am one of 
those who deny the existence of the contagious fever which is 
produced by the human body, so long and so well known; since 
if there is aught of evidence in physic, the evidence for this is 
most uncontrovertible. 

All that now remains is, to speak of the treatment of the 
chronic or relapsing remittent; while the remarks applicable to 
it may be equally applied to that disease or those diseases of si- 
milar character, the relapsing quotidian and the double tertian; 
terms, which if it were of any importance here to be very ac- 
curate and minute, would probably apply with more justice to 
the majority of cases that occur in actual practice. 

I know not that I should be very wrong if I were to com- 
mence by saying, in an equally sweeping manner as of the sim- 
pler modification of remittent last discussed, or of the sim- 
ple fever without returns, that it is incurable by medicines, or 
beyond their power. I know of no great average of instances 
at least, in which the returns or relapses have been prevented 
by mere medicines, or where those seem to exert any influence 
for good, over the paroxysms of each relapse, or over the total 
state of a whole relapse. The inveterate career of this disease 
appears to be equal to its obstinacy of character in each recur- 
rence. 

If however the relapses be severe, the same rules apply as to 
the single disease, and those I need not repeat; but that relapse 
past, no remedy, no medicine at least, appears to prevent the 
habitual and expected return; or the returns are the same in 
point of period and force, where medicines have been used in 
the interval and where they have not. And it is in this dis- 
ease that bark, arsenic, and the remainder of the tonic reme- 
dies, seem to be peculiarly without power; and not less so when 
•the intermissions during the relapse, or the commencements of 



102 cure or 

each paroxysm, are so well marked as to leave no hesitation in 
referring it to the quotidian and double tertian rather than to the 
proper remittent. 

This at least is the result of my experience, and pretty gene- 
rally of my reading also: but I shall be very well pleased to be 
contradicted by any one who may have had more success with 
medicines; as there is perhaps no disease in the whole catalogue 
of human miseries, attended with greater suffering, and not one 
with equal inconvenience. To spend years of life in the suffer- 
ings of fever, sufferings which a spectator cannot appreciate or 
even comprehend, indefinite as they are, and unmarked by vi- 
sible disease or by absolute pain, however well known to those 
who have felt what fever is, might be even misery enough, 
comprising as they do, bodily evils as unceasing as they are nu- 
merous and distressing. Add to this, nights resembling the 
days, sleeplessness, often with that delirious activity of mind 
which aggravates the present as it anticipates further evil, which 
longs not to think, but is compelled to be ever thinking: add 
to it the consciousness of ability for mental exertion, yet the 
perpetual torment of being for ever checked in the attempt, 
the utter insensibility to every pleasurable feeling or impression, 
the dark present and the darker future, the " lasciate la speran- 
za" which is so highly characteristic of this disease; add to it 
again the persevering coma, where the patient cannot rouse him- 
self, yet cannot sleep, and a slight idea, slight indeed, may be 
formed of this tormenting disorder; less known, fortunately, to 
our happier climate, than to those pestiferous regions described 
in the first part of this essay, in which life is, most literally and 
truly, one long disease, and where death is indeed the only phy- 
sician. 

And let the patient too who has idly calculated on the tole- 
rance at least, if not on the sympathy of imagined friends, not 
forget what he has endured from their neglect, contempt, incre- 
dulity, or tyranny, if he would induce physicians to labour in 
discovering the means of curing this opprobrium to them and 
their art. Nor let him forget the continual insecurity, even in 
the periods of tolerable or comparative health; the insecurity? 
the certainty on the contrar}'-, that he dares not leave his home, 
that he dares not adopt that change of place, or follow that sys- 
tem of foreign travel which is recommended as a cure, that he 
dares not form any plan of life, even from week to week, as- 
sured that whatever he designs to do will be defeated, that if 
even his life is safe, he holds his health on a tenure which ren- 
ders life useless. And if this be the picture, (and a slender 
sketch it is of the truth) let physicians remember that this is not 
a solitary, not even a rare case. It is the history of tens of thou- 
sands, in every country of the world, over all that geography 



REMITTENT. 103 

which I have noted, and far more; the prime curse of mankind, 
availing to their torment, while little availing to the useful ends 
of disease, the thinning of the human race; since, if it is the pic- 
ture of this fever, so is it that of every chronic intermittent, be 
its character what it may. 

Yet is this disease occasionally cured; while, however, there 
is little in the power of mere medicines. Revolutions in the con- 
stitution, of which we can give no account, do terminate it after 
an uncertain series of years. On similar principles, probably, 
it is removed by the occurrence of other severe diseases, as even 
the more acute intermittents sometimes are: and there is no one 
who would not willingly undergo the longest periods of the 
heaviest visitation in the catalogue, in exchange for it; often 
even with all the hazards that may befall. 

Of what is in our power, if it is always just to the patient to 
labour through the whole round of tonics, with whatever little 
hope, there is nothing which seems really efficacious but change 
of habits; change of air, change of climate, change of every thing. 
And thus is the disease sometimes extirpated. But the value 
of this remedy is greatest when that change is from a soil pro- 
ductive of Malaria, or from any other situation generative of the 
causes of the disease; for by this is it often kept up, when it 
would otherwise disappear. Thus, as I formerly hinted, is it 
often supposed to be an habitual disease of the constitution, or 
even a disease dependent on organic affections, when, in truth, 
it is not a disease of relapses, but a succession of new diseases, 
produced by repeated applications of the cause. 

Nor can I help thinking that this remedy is of much more 
general application than it has been commonly esteemed; in 
every case at least where the patient suffering, or having suf- 
fered, from fever, would otherwise remain in the place where 
the disease was produced: the corresponding neglect' arising 
either from mistaken views of the nature of the fever, or from 
ignorance respecting the sources of Malaria. In chronic cases, 
or after the termination of the disorder, this expedient is very 
frequently or generally resorted to in tropical climates; yet even 
there, very often, without any definite ideas of its nature or ac- 
tion: and hence the practice of sending West Indian patients 
into the mountains, African ones to sea, and East Indian in- 
valids even to Europe, where the object might often be at- 
tained by a much more moderate and less inconvenient migra- 
tion. But in our own country, it is far too much neglected; or 
rather, it is scarcely known, or considered as a remedy, so that 
a protracted disease or a series of relapses is a frequent, conse- 
quence; or else, in the fenny counties, an inveterate intermit- 
tent becomes the vexatious result of this neglect. And the 
cause of this must be sought in that obstinate and still ineura- 



104 » CURE OF 

ble ignorance which will persist in considering our autumnal 
fevers as typhus; repeating the same error year after year, and 
profiting as little by experience as by all that has been written 
on this really most simple subject. 

Hence the unfortunate patient is retained where the poison is 
ever active around him, ever active and ever acting, prolonging 
a disorder that might have terminated in three weeks, to six, or 
leading to relapse after relapse, or, lastly, causing the fever to 
settle into that intermittent form, which is so apt to become the 
inheritance of life. 

Thus, to give a familiar and tangible example, in this year, 
1826, have the inhabitants of innumerable places in England, 
suffered severely and widely from fevers; proving also, that 
production of Malaria in those districts to which I formerly al- 
luded, as it further proves the power of a hot summer, in aug- 
menting that production, while it is even doubtful, if one such 
attempt at removal or change has been suggested, in any one 
part of all England, even in the fenny counties, or in those 
places where the cause of the disease is known, and its produc- 
tion from the soil acknowledged; though, in most places, the 
name typhus has been as generally conferred on it, as is usual in 
all such cases. 

This general assertion I could easily prove by a great mass of 
specific facts, were it not for the reasons assigned in the essay 
on Malaria, though I may venture at least, to say that I could 
point out many towns and villages, even in the neighbourhood 
of London, where almost every house has been affected by fe- 
ver, and where, in some, every resident individual has under- 
gone the disease, while in those, the causes of Malaria have 
been most palpable, though the disorder has been called typhus, 
and not one attempt has been made to remove a patient from the 
place, even when one after another in the same house was sick- 
ening, sometimes dying, and when relapse after relapse was the 
lot of those who escaped. Thus also could I name villages in 
Lincolnshire, in Essex, Kent, Sussex, and in many other parts 
of England where the people really are aware of the cause, 
if perhaps carelessly viewing it, and in many of which not a 
house escaped in this summer, and in which also the greater por- 
tion of all the inhabitants were affected: falling under the dis- 
ease one after another during the whole autumn, and even dying 
in a fearful proportion, yet making no attempt to quit places 
which the practitioner at least should have known to be the 
cause of all this disease and mortality, as containing distinct 
sources of Malaria. Not to name these exact places, is perhaps 
an unnecessary refinement of caution, as it relates to any injury 
which might be suffered from specifying, for salutary ends, and 
with useful views, that which is known to thousands. But, 



REMITTENT. lOo 

having adopted the rule from good motives, I must abide by it: 
while, perhaps, it will not only serve the same purpose, but be 
even more satisfactory to persons to whom these places are 
known, as ordinary residents, or as practitioners, to make these 
remarks for themselves, each as to the district which may be his 
own; taking for his guide the general statements made in so 
many parts of this and the preceding essay. Or, to profit by 
these remarks, let an inhabitant of Woolwich or Greenwich, for 
example, places in reality very little and very rarely affected by 
these fevers, or let a resident at Marston in Lincolnshire or at 
Hythe in Kent, as situations more exposed to the causes, inves- 
tigate the number and characters of the fevers of 1826 about 
him, then reflect on the nature of the summer, the direction of 
the winds, and whatever more may be necessary, next examine 
the lands, and attempt to discover where the Malaria is pro- 
duced; lastly, endeavouring to find out, as to any specific case, 
when and how the exposure took place, and I cannot doubt that 
he will come to the same conclusions which I might here have 
drawn for him; convincing himself that the fevers in question 
were remittents, and the causes those which I have here de- 
scribed, and, further, acquiring that discrimination as to the 
causes, which will become to him a source of that practical uti- 
lity which it is the object of this work to inculcate. And that 
his own conviction, thus produced, will be more impressive 
and useful than any belief which he could have adopted from 
me, I cannot for a moment doubt; while I do not wish to claim 
belief as a due, nor desire concurrence to any thing which is not 
absolute evidence. 

There can be no hesitation in making it a general rule, even 
among ourselves, and in a milder disease than that of the tropi- 
cal regions, that every patient under a fever in summer or au- 
tumn, be its appearance what it may, or though its vulgar name 
be typhus, should be removed to another situation whenever this 
is possible, and most particularly whenever the present habitation 
has produced the disorder or is productive of its causes. There 
is here at least a chance of shortening the duration of the fever, 
and also of rendering the existing symptoms milder: and though 
the success in such cases cannot be proved to be very conspicu- 
ous or very certain, since those who doubt can always withhold 
their consent as to the cause of any event, there can be no ques- 
tion whatever of the great utility, or rather, of the absolute ne- 
cessity, of such removal, as soon as the patient becomes in the 
slightest degree convalescent; as thus we have the best, often the 
only chance, of preventing relapses or final intermittent. 

It would be abundantly easy to quote cases in proof of the 
truth of these views and the success of this practice, both at 
home and abroad, in single instances, and on the great arithme- 

14 



lOO CURE OF 

tical scale of naval and military service; but I must content my 
self with a mere specimen or two from the latter class of re- 
cords, and chiefly because naval and military surgeons will find 
no difficulty in confirming them from their own experience. 

In the first example, out of sixteen men from a frigate, under 
the African fever and in the hospital, eight were taken on board 
and to sea, the other half being left on shore; the consequence 
being, that all the former cases recovered perfectly and without 
relapse, while every one of the remainder subsided into an ob- 
stinate intermittent. This is a pointed case on a small scale. 
A recent and a very conspicuous proof, on a far greater one, of 
the utility of removing the convalescents from fevers to a healthy 
district, occurred at Rangoon in the late Birman war: the troops, 
in great numbers, which had continued to be sick and incapable 
of duty for many months at that place, after the fever, having 
recovered immediately and perfectly on their removal to Mer- 
gui. And though I must not suppose that in this particular in- 
stance, that proceeding was not adopted as soon as it was possi- 
ble, it is but too obvious, that, apparently from the lax ideas 
entertained of the purpose and value of the change of air, as it 
is always idly called, in these cases, the greatest neglect has 
often occurred in similar circumstances, and that the deaths of 
thousands, as well as the inefficiency of armies, have been the 
consequence. And if I could produce some analogous facts from 
my own observation, I doubt not that this class of medical ob- 
servers can recollect many more, and also better marked, where 
even the tropical remittent has been actually cut short by simple 
removal, in cases where circumstances of retreat before an ene- 
my, the necessity of leaving a station, or aught else, has com- 
pelled the sick to be removed; and even where death had been 
expected to follow the mere attempt at a conduct so apparently 
violent and hazardous. 

With such views, and which I trust are not only well found- 
ed, but will prove so in practice, should they ever be received 
among ourselves with favour, it is not easy to contemplate with 
tranquillity the facts which every autumn exhibits in England, 
and which that of 1S26 has perhaps displayed, as I have just no- 
ticed, in as high a degree as any modern seasons have done. In 
hundreds of places, besides those to which I have just alluded, 
we might have found in every one of the past years, as we shall 
doubtless find again, whole families, even whole villages, attack- 
ed one after the other, and individual after individual, with 
this fever, yet all suffered to remain, in spite of such warnings 
till all had sickened and many died; and even those who had re- 
covered, kept on the same spot, in the same house, till relapse 
after relapse had ruined the patient's health or perhaps termina- 
ted his life. 



REMITTENT. 107 

If such carelessness took place respecting the poor only or 
the lower classes, there is the ample excuse that it is impossible to 
remove them; but nothing but pure ignorance can explain this 
conduct as to the opulent, whose chance has hitherto been scarce- 
ly better than that of their inferiors. If I could produce cases at 
the very moment I am writing this interpolation, where nine, 
ten, sixteen persons in one house, and in opulent families, have 
been permitted to take the fever, gradually, in a succession of 
four, five, and six weeks, with the loss also of some patients, 
and when the neighbouring land too was a land of meadows and 
ditches and half the lawn was perhaps a fish-pond, there is no 
excuse, as there is no solution but in the ignorance of the prac- 
titioners. And if that consists in not knowing the value of a 
change of place, and in not knowing also, or not believing, that 
such land will produce Malaria and fever, it is founded perhaps 
even more on that most unfortunate, yet almost universal error 
which I am never weary of repeating, that of calling and con- 
sidering these fevers typhus. 

That such is the belief even now, 1826, among the people, 
and, what is the real misfortune, among practitioners, in spite 
of all experience, is amply proved by common conversation, by 
the newspapers, by the very language of practitioners them- 
selves. That such it has generally been, is not less certain and 
less proved; while successive seasons arise without teaching 
those to whom experience can teach nothing: not even in Lin- 
colnshire, as I have just said, where at least, the nature of the 
disorder might have been conjectured, and where the value of 
the remedy ought surely to be too obvious to be overlooked. 
And I must think it extraordinary, in physic, at the present day, 
and so soon after a war which must have rendered the nature of 
these fevers generally known, that in more than one village, 
even of Lincolnshire, not to mention hundreds of other places, 
not merely was the character of these fevers mistaken to the 
very last, but half of the entire mortality had occurred before 
the practitioners had made up their minds how the epidemic 
was to be treated; seeming indeed to have even forgotten that 
there was such a disease, and expressing an alarm, as well as a 
surprise, at an occurrence which, if it has been rare in England 
of late, might have been found from history, medical or ordi- 
nary, to have been once sufficiently common; as it should have 
been still better known to be the common epidemic of analogous 
wet situations on the continent of Europe. That I do not name 
these specific places, which I might full easily do, is that I may 
avoid a species of criticism which, however useful to the public, 
might be painful or injurious to individuals. 

Here then we see more distinctly, the value of the remarks 
on pernicious soils and on the propagation of Malaria, which 



10S CURE OF 

have been detailed in the essay on that subject. It is this study 
which must form the real basis of the cure, in this as in all the 
chronic or repeated intermittents. The cure consists in the 
avoidance of fresh causes, new excitements: and, to be enabled 
to apply it, these must be familiarly known, accurately studied, 
and carefully investigated. He who would be the real physi- 
cian here, must be the acute observer and the philosophical na- 
turalist; for where he cannot act he must learn to avoid, since 
the cure is negative, and in avoidance as the remedy. 

And now may also be further seen the value of this know- 
ledge in a more general and geographical view. It is to rush 
into the lion's mouth, to leave the Malaria of England for the 
ten times more destructive ones of France and Italy: and thus 
it is that the foreign travel which is intended for the cure, be- 
comes too often the aggravation, or perhaps the source of death; 
as it sometimes thus is, when resorted to for chronic diseases 
whose nature is misunderstood, and which are misnamed; for 
disorders which, in reality, depend on the same causes, or ori- 
ginate in the very Malaria, to which, in a degree a thousand 
times more diffused and active, they are sent for a remedy. 

I cannot enforce this in stronger language; while I wish I 
could believe that this would have the effect of making careless 
physicians pause in their recommendations of foreign travel, or 
at least inquire what the country is to which they send their un- 
fortunate patients, too often from weariness or the dread of re- 
proach. And if, here also, we can see more distinctly the va- 
lue of that work so much to be desired, a statistical or geo- 
graphical detail of Malaria, there is nevertheless a considerable 
extent of this knowledge to be procured by those who will seek 
it in those geographical works and books of travels which 
abound, and which it is highly discreditable in the physician 
who thus tampers with the lives and healths of his patients, not 
to know. Long ago did Smollet, a physician himself, remon- 
strate against Montpellier, in a much more simple and obvious 
case; and yet does a culpable ignorance still consider it the pro- 
verbial Montpellier which it was once so falsely said to be. 

But to return from a subject which I cannot prolong here, and 
for which the plan of this essay cffords no room, I must now 
remark as to the cure by change of place, that while that change 
requires a very obvious selection, on the principles now laid 
down, it is also often very useful to repeat it from time to time. 
Thus it will happen that the first change will terminate the pre- 
sent disease, or protract the interval of health beyond the usual 
period. Still the disorder again returns, and it must then be 
met by a fresh change; while it is often successful, even to re- 
turn to the original place, provided it is not in itself an un- 
healthy one, as it become? convenient when the patient's cir- 



REMITTENT. 109 

eum stances do not admit of any other. Thus, frequently, may 
the disorder be kept at bay; or the persistence of the several 
returns is gradually reduced, or else the intervals prolonged, till 
it finally vanishes altogether. 

I need not enlarge on this practice, of which however the in- 
convenience is unfortunately too palpable, as it is too frequent 
and too great; since it cannot often be very applicable, except 
to the independent or opulent, implying, as it does, so many ob- 
vious sacrifices. It remains to examine into the utility of the 
only mere medicine, besides the tonics, which I know of, name- 
ly mercury. 

On the presumption that the chronic fevers of this class were 
necessarily connected with organic diseases of the visceral 
glands, this remedy has naturally been recommended and fol- 
lowed. That it does act in the chronic inflammation of the li- 
ver as in the acute one, admits of no doubt: but there are many 
physicians of far greater experience than myself, who doubt 
with me of its power over the other chronic diseases, the real 
permanent diseases, or the obstructions as they are called, whe- 
ther of the liver or the spleen. But this is a subject by no 
means so clear, difficult as it is to discover what the exact state 
or nature of the disease in these glands may be, as to prevent 
us from trying a remedy which is often doubtless a powerful 
one. That it is a practice often rashly and injuriously pursued 
in the present day, and especially in England, is however but 
too plain; while it is easy to trace the origin of this pernicious 
abuse to the physicians of our colonies, and especially to opi- 
nions formed and fostered in India. 

To enumerate the evils now daily produced, by this medicine, 
in all its forms, in innumerable disorders and patients, by what 
a French writer, censuring English practice, calls " Pinevitable 
calomelas," and not only in real disorders but in imaginary 
ones, and in subjects that may be considered healthy, would be 
a task worth undertaking; while it is one on which I must not 
venture in this place. It is, or has recently been, a fashion, al- 
most amounting to an insanity, and which has not merely abused 
this active and hazardous substance in medical hands, but which 
has rendered it familiar to those, a now numerous class in this 
age of universal aspiring, and of assumption especially on the 
subject of medicine, who take upon themselves to treat their 
own diseases, real or imaginary, and, still less pardonably, the 
ailments of their acquaintances. If, besides the unconscious dead 
there are thousands living to rue the day when mercury became 
the Universal Medicine in the hands of English physicians, 
there are tens of thousands who, if they were conscious of the 
fact, should lament the hour when first they imagined them- 
selves qualified to practise that which he who has studied it most 



110 CURE OP 

and longest finds the most difficult of arts, and the more he stu- 
dies it, the more difficult, and who should repent too, that they 
ever knew, even the very names of " calomel and blue pill." 
Well may entire Europe wonder at English practice; and more 
still may it express its surprise at that universal self-empiricism, 
before which all the professed quackery of all Europe shrinks 
into nothing, and in comparison of which the temporizing 
ptisanerie of France is absolute philosophy. 

To return. If the visceral glands are disordered, the cure of 
these is an obvious claim on the physician, whether they should 
be a maintaining cause of the chronic fever or not; and a judi- 
cious physician will here act with those necessary cautions for 
which it is impossible to lay down rules. But I must point out 
one ground of caution as to the fever itself, from ample experi- 
ence of the evil effects of mercury as to it, and of effects, as far 
as I have seen, very little suspected. 

I have formerly said that its recurrences are produced by any 
debilitating cause, and it would not be very easy to find one 
more active to this end than mercury. As for calomel, as a pur- 
gative, injudiciously pursued, repeated beyond utility or obvious 
necessity, it is one of the most pernicious of the whole tribe, 
while even thus it also produces its constitutional action. In- 
ducing salivation, in this or in any other form, I need not point 
out its effects of this nature; while its effective use, far short of 
this, induces also a state of debility which often becomes dura- 
ble; lasting long after the proper effects of the remedy have dis- 
appeared, and sometimes appearing to last even through the 
whole of life. 

Thus it happens that from the injurious effects of mercury, a 
chronic disease of this nature is rendered more inveterate; or 
new accessions, finally becoming a habit, are brought on, when 
the disease might otherwise have terminated of itself, as it so 
often does. And if in persons thus artificially debilitated, the 
effects of other occasional causes in re-exciting the disease are 
augmented, so are the sufferings of the patient increased by the 
feebler powers of resistance, opposed to the action of the disor- 
der. I have such unquestionable evidence of the aggravation 
and the protraction of these fevers from the use of mercury, 
that I have often been inclined to doubt whether it should even 
be hazarded when there is demonstration of visceral disease ac- 
companying it: and if, as is supposed by the most judicious phy- 
sicians, the fever is itself the cause of the glandular affections, 
it is plain that the imagined remedy becomes in these cases a 
poison. Let practitioners at least attend to this fact, and watch 
carefully the effects of the remedy, for good or evil: and thus 
will it be comparatively easy to form a correct judgment re- 
specting its propriety or utility. And it is a caution the more 



REMITTENT. Ill 

necessary, because it has been boldly asserted, and by hundreds, 
that in this as in all cases of chronic intermittent, mercury is 
not merely a remedy, but the remedy, a specific, while it is a 
doctrine, by which thousands have been misled. 

On the other hand, now, so intricate is physic in every point, 
there can be no question that in this assertion there is some 
truth, or that there are cases in which mercury does most clear- 
ly produce a cure. That it has produced such cures while it 
also removed glandular affections, there is no doubt; while it is 
further possible that the cure of these disorders may have been 
the removal of the causes of the fever. But it is certain also, 
that it does cure this disposition to the renewal of fevers, even 
when there is the most perfect demonstration of a healthy state of 
all the viscera. In this case it seems to act by inducing a new 
disease, or an entire change of habits; just as acute diseases of 
various kinds remove it, or it is removed by any other impor- 
tant change in all the habits. Thus have I seen habitual fevers 
of this nature gradually disappearing under the use of mercury, 
while it was easy to trace the progressive connexion between 
the effects of the remedy and the diminution of the disease. 

How impossible it is to give rules for judging oft the cases in 
which it may thus be useful, must be very obvious; nor can it 
be judged of but by the physician's own discernment. But 
with respect to its administration, my own experience has 
shown that it ought never to be so pursued as to induce its ob- 
vious effects, or even any marked debility; though 1 have at the 
same time time seen cases, where, on the occurrence of the first 
symptoms in the mouth, an habitual remittent of many years 
standing had disappeared to return no more. Nevertheless, a 
temporizing practice is perhaps the most generally applicable, as 
it is the safest, while it may thus be sometimes carried on, even 
for years, with perfect security, with the final cure of the dis- 
ease, and with no apparent evil results. 

So uncertain is medicine, and so difficult must it continue to 
be to reason respecting it, while we remain so imperfectly ac- 
quainted with all its fundamental principles. I shall only add 
here in concluding this account of the means of cure, that where 
mercury has been thus found to cure what is called dyspepsia, I 
have much reason to believe that the cases have sometimes been 
truly the slighter fevers of this nature which I pointed out for- 
merly. Yet I must subjoin, that if I have here omitted to no- 
tice those varieties of the remittent which I have called anoma- 
lous, it is because as far as any peculiar treatment is required, 
this will be better reserved to the place where I shall discuss the 
remedies of anomalous intermittents. 



[ ns j 



CHAPTER Y. 



On the Dysentery and the Cholera. 

Since dysentery is one of the most important and severe of 
the disorders produced by Malaria, I could not absolutely omit 
all mention of it, inasmuch as it might be supposed that I had 
either formed erroneous views of its cause and nature, or did 
not perceive that it formed a most important link in that great 
chain by which pure fever from this cause is connected with the 
local affections which that also produces. But if I am unwilling 
to treat of this disease under the limited and imperfect experi- 
ence which I possess respecting it, and which is not easily at- 
tained in this country, while I can at the same time refer to au- 
thors out of number, from whom I could but compile, and 
whom I ought not to pretend to elucidate, I am scarcely less 
disinclined to inquire respecting its proximate cause, or in what 
manner and from what circumstances it differs from fever, see- 
ing that it is produced by the same general cause, Malaria. Yet 
in future parts of this essay, there will be found some remarks 
respecting the localization of this class of disorders, or, as re- 
lates to partial affections or symptoms superseding a general 
morbid effect, or united with that, which will perhaps con- 
vey some idea of what I would have said on this subject, had 
our knowledge been such as to allow of more accurate and defi- 
nite language than it is possible to apply to such discussions at 
present. To illustrate, slenderly, what is here meant, we have, 
in severe cases of the remittent fever, that local affection of the 
stomach which causes the black vomit, that analogous one of the 
liver which produces what are called bilious symptoms, affec- 
tions of the head,, &c, besides all the more rigidly local and 
partial diseases of which I have here treated at some length. 
It is not therefore difficult to comprehend, yet very generally 
and broadly, how such localization , or determination to the in- 
testines, may produce dysentery; while this will vary as fever 
is conspicuously combined with it, or as the local affection is 
such as to supersede in a great degree the general one: while 
yet further, it is easy to imagine that if the affection in ques- 
tion should attach preferably to one or to another portion of 
the intestines, to the duodenum for example in one case, and' to 
the colon in another, (a fact very conceivable from their differ- 






DYSENTERY AND CHOLERA. 113 

ences in character, structure, or sensibility,) all the varieties of 
dysentery as to the most obvious effects might be the result. 

Such a view, put into other language, becomes similar to that 
French theory, often differing from former ones only in its terms, 
which supposes dysentery to be an enteritis, or to consist in an 
inflammation of the mucous membrane; to be, according to cir- 
cumstances, a. gastro-colite, a gastro-duodenite, and so on. It is 
however, as thus expressed, little more than a theory of words; 
when the very same affections are held to be the cause of re- 
mittent and intermittent fevers. There is much more required 
before we can explain to those who look beyond words, why 
the same poison should in one instance produce mere fever, and 
in another mere dysentery; particularly if, in both, inflamma- 
tion of the same organs is esteemed the proximate cause. 

Thus much at least of what may approach to a theory of dy- 
sentery, seemed necessary for the purpose of tracing its general 
connexion with mere marsh fever. In our own country, it is 
neither frequent nor severe, while the treatment is in general 
equally simple and well understood: and as it occurs in other 
countries and climates, it has been so amply described by nume- 
rous authors that any notice of that would be as superfluous as 
inconsistent with my plan. I shall only remark, that, with us, 
it is very commonly mistaken for diarrhea by the mass of or- 
dinary practitioners; a recent notorious example of which I need 
not call to the reader's mind: while, fortunately, being general- 
ly slight under this error, and while there is also no small con- 
fusion respecting the proper treatment of mere diarrhea, no great 
injury is the consequence. I should remark however, that 
whatever well-known and essential distinctions there may be 
between dysentery and diarrhea, there are instances in practice, 
where in an autumnal disease of this general character, arising 
in persons exposed to Malaria, the term diarrhea is the most ap- 
plicable; as it is in reality given, and especially by those, the 
very great majority, who are not aware that our own diseases of 
this leading appearance are the produce of that influence. Hence 
an excuse for the original error as to the penitentiary; while I 
can add, that in a parallel case often submitted to my temporary 
charge in former days, namely the Woolwich hulks, every 
symptom of the autumnal disease in the very great majority of 
patients, which often included the whole of the prisoners, was 
that of diarrhea, and nothing more; so that but for the collate- 
ral and obvious circumstances of place, season, and so forth, 
together with the occurrence of some marked cases of true dy- 
sentery out of the number, I should have pronounced it an or- 
dinary diarrhea. In reality, there does not seem any very 
marked limit in practice between these two disorders, however 
theoretically different: or rather, while there are diarrheas which 

15 



114 DYSENTERY AND CHOLERA. 

bear no relation to dysentery, there is one, arising also from 
Malaria, which is not radically distinct from it. And I ima- 
gine that this must be nearly the opinion of French physicians 
acquainted with the distinct production of Malaria; because a 
diarrhea of great obstinacy is marked as one of the endemics of 
those situations. Nor is this difficult to understand theoretical^: 
as it is easy to imagine that the local peculiar inflammation 
which is the cause, may vary from the simplest affection to the 
most violent; from little more than mere irritability to positive 
ulceration. 

Here also, and for the same reasons, I cannot avoid putting 
some queries (I cannot well call them more) respecting cholera, 
and particularly respecting the disease so termed, which has of 
late excited such attention in India. It is necessary to speak 
with caution of what we have not seen, and of a disease indeed 
so very imperfectly described, that it is far from easy to com- 
prehend what its nature and characters are. Yet from some 
facts that have been related to me by accurate observers without 
system or prejudice, officers ignorant of medicine, and therefore, 
as I believe, the more to be trusted in a case of such evidence, 
I cannot help concluding that it is a disease to be added to the 
products of Malaria; notwithstanding the decided opinions to 
the contrary which have been held by some of the disputants 
on this question: an opinion which rendered it imperious on me 
not to pass it without some notice, however slender and con- 
jectural. 

Of these facts, one will answer the purpose as well as the 
whole; since the nature of all is the same; while that which I 
have selected is pure, or free from distracting circumstances. 

A frigate had cruized long on the coasts of India where this 
disease was raging on shore, retaining her health however, and, 
as was believed, by rigidly avoiding any communication with, 
or even approach to the land; the captain's conduct in this re- 
spect having arisen from his experience of African fevers. Be- 
ing on one occasion-at anchor about three miles from the shore, 
the land wind came off to the vessel, and with such effect that 
the usual smell attending Malaria, well known to the officers 
and men from their African experience, was immediately sensi- 
ble. There was not at this time a sick man on board, while 
there had been no communication with the land for many weeks: 
and the alarm being immediately taken, the vessel was ordered 
to weigh for sea; while, as had been the constant practice, every 
man not wanted on deck was ordered below, for the purpose of 
avoiding the effect of the Malaria thus blown off to sea in the 
manner which I have described in the essay on that subject. 
An accident having happened to the iron cable, the armourer 
was the first man employed, almost alone, on deck, in disengaging 



DYSENTERY AND CHOLERA, 115 

it; and though in perfect health when he came up, he was im- 
mediately seized with giddiness, was quickly rendered incapable 
of proceeding with his work, became insensible within three 
hours, and died of this cholera, w"hich also seized on four of the 
crew before the vessel could get under weigh; the whole of them 
dying in the same manner. 

Such evidence as this seems to establish that a Malaria is 
the cause of this cholera also, to whatever circumstances it may 
be owing that the produce is not the usual fever. And if so, it 
may be conceived to be in a state of unusual activity or viru- 
lence; the effects in question bearing an analogy to what some- 
times happens in the plague. In this disease, further, the local af- 
fections of the stomach and bowels, or of these and the liver 
together, are the most remarkable symptoms; or we may consi- 
der it as a localized remittent of peculiar severity, and with two 
or three local affections at one time. Thus, to illustrate, it might 
be compared with black vomit, with dysentery, and with ordi- 
nary -cholera, all united; or as also happens, with the two for- 
mer combined, without the third: or, at one and the same in- 
stant, there is a local action in the stomach and in the liver, the 
first, if not precisely the black vomit, being a state analogous 
to that, or intermediate between it and the more moderate af- 
fections of this organ occurring in remittents of less severity. 

If this view be the correct one, this most remarkable disease 
is not the proper cholera known to us, but is rather a peculiar 
remittent with local affections, at once numerous, extensive, and 
violent; a fever in which minutes perform the destructive duty 
of hours, days, or even weeks, or in which, from its rapidity, 
there is scarcely an initial stage; as if the disorder had com- 
menced where it more usually terminates. Under such a view, 
it is almost superfluous to say how little are the hopes of a cure, 
at least for the severer cases, by any means as yet in the pos- 
session of physic. 

This is all that I can venture to say on a disorder which I 
have not seen, and respecting which what I have read (which is 
I believe all that has been written) has not given me any very 
definite ideas. Whatever obscurity as to its cause or nature re- 
mains, thus much at least is certain; since the solitary case which 
I have recorded is as perfect as a thousand could be, or since it 
is one of those pure facts which, in science, forms evidence as 
complete as the greatest number could do, and infinitely more 
so than a million of cases where the same simplicity is not pre- 
sent. That deduction is; that this cholera is the produce of an 
atmospheric transportable poison, generated upon or by land, 
resembling therefore Malaria in all its obvious properties and 
origin; while if it is not the same Malaria which produces re- 
mittents, and the disease is not a mode of that great class, there 



116 DYSENTERY AND CHOLERA. 

must be Malarias of different chemical natures, capable of pro- 
ducing very distinct disorders. 

This was a question brought forward in the essay on Mala- 
ria and left unanswered: while if it shall be concluded that this 
is the fact, then may there be many more Malarias, as was sug- 
gested in that place; or the several kinds of fevers, as well as of 
other disorders, namely, tertian, quartan, remittent, and so on, 
together with their endless modifications, and together also with 
cholera, dysentery, and even the several neuralgias, may be ac- 
tually dependent on Malarias of as many different qualities or 
chemical modifications. Thus will each variety be productive 
of its specific disease, as the different contagions are; though 
should this appear groundless or false, we must rest in the ori- 
ginal belief that these different disorders depend, severally, on 
quantity or virulence, as I have suggested above, or on collate- 
ral circumstances influencing the body as predisposing and mo- 
difying causes; since we have but that apparent alternative. All 
this is indeed but conjectural, or possible: but it opens wide 
views respecting a subject of great interest both in a chemical 
and a medical view; and a subject also which I do not despair of 
seeing hereafter elucidated by that chemistry which is yet des- 
tined to do for us, things of which we have despaired, and 
much also respecting which we can scarcely now even form a 
conception. 

And this leads me also to offer a few remarks of a similar na- 
ture on the genuine or ordinary cholera; since this too seems to 
be one of the disorders that is produced by Malaria. Here also 
I shall not treat of a disease so well known and so common; as 
English experience does not suffice to enable, probably, any one 
to understand it thoroughly, and, still more, to question the pre- 
vailing opinions and practice. 

It has been generally thought, that the action of the sun, or 
of heat simply, long continued, if our climate is in question, 
less necessarily protracted in a tropical region, was the cause of 
cholera; or that, from such an action, the liver became gradually 
disordered, so as at length, and by a species of accumulation, to 
break out with the symptoms of this violent and singular dis- 
ease. The same doctrine has been applied, I need not say, to 
autumnal or remittent fevers in general, as occurring with us 
in England; while I have here attempted to show that this hy- 
pothesis is gratuitous or conjectural, if not as yet demonstrably 
in all, yet at least in the great majority of cases; and that what- 
ever this cause or others may effect, the true or prevailing source 
of such fevers must be sought, in our own, as in the hot climates, 
in Malaria; though that is seldom or never noticed, from inat- 
tention to the natural history of this poison, or from ignorance 
as to the soils which produce it, or from prejudices respecting its 






DYSENTERY AND CHOLERA. 117 

exclusive attachment to the swamps and marshes of Italy and 
Holland. 

With respect now to cholera, I have here, in speaking of re- 
mittent, followed the common opinions in supposing that mere 
heat could affect the biliary system, and thus modify the nature 
of such a fever; nor am I about to question openly that this may 
not be the case, and that perfect cholera may not be produced 
without the presence of Malaria, however I may think it ne- 
cessary that this subject should be reviewed by a fair series of 
observation, instead of being taken for granted, as has hitherto 
been the case. Yet let us remark the following circumstances; 
and we may then perhaps be inclined to doubt whether the pre- 
vailing theory is the true one, and whether this disease, like re- 
mittent and dysentery, is not the produce of a cause common to 
the whole: the distinction consisting in the part or organ to 
which the local action is determined. 

If heat alone were the cause of cholera, it should be produced 
in the earlier parts of the summer, supposing that such summer 
had been both early and warm; or if it required one month, 
or two, of the sun's action to generate this derangement of the 
liver, it should be indifferent at what part of the year that was 
exerted. The same argument indeed applies to the case of re- 
mittent; equally, and probably under the same error, supposed 
by many physicians to be the produce of mere heat. But, in 
practice, cholera, as well as remittent, is a disease of autumn; 
or it appears together with fever and dysentery, after a long, or 
a certain, duration of heat, and when, as is now admitted in as 
far as remittent and dysentery are concerned, some change has 
taken place in the vegetating surface of the soil, to which is 
owing the production of Malaria. 

Further, cholera belongs, predominantly if not exclusively, 
to the same climates, the same soils, or, generally, to all those 
countries and places in which the other diseases of Malaria 
abound; and if as numerous in respect to cases as these are in 
such places, resembling them also in severity. Reversely, it is 
rare in the reverse climates and countries or places. Of this 
we shall easily be convinced, even in our own; as the most su- 
perficial examination will show that this disorder is common 
where fevers are common, and rare where they are rare, that the 
places where both appear are precisely those which indicate the 
existence or probability of Malaria, and that autumn is equally 
the period of all. What may also serve to confirm this is, that 
where the present autumn, 1826, like some of the preceding, 
has been remarkable for the number of fevers, these having been 
also conspicuous for heat and for the prevalence of east winds, 
cholera has been far more frequent than in former and distant 
years; and that it has thus appeared even in Scotland, and al- 



118 DrSJENTERr AND CHOLERA. 

ways most remarkably in low and wet situations, where its ex- 
istence had been formerly unknown. 

Such are the direct facts which may lead us to infer the com- 
mon origin of these several diseases, or to attribute cholera to 
Malaria, even though we cannot assign the accessary cause which 
determines the action of this poison to the liver in such cases, 
rather than to the brain or the whole nervous system, as is pro- 
bably the case in fever. But this offers no further difficulty 
than dysentery ; since here also, through causes which we can- 
not at present discover, the chief action of the Malaria is ex- 
erted on the intestines; and still more remarkably on a specific 
portion of those. As to these difficulties indeed, or in as' far as 
the collateral causes which determine the local action of Malaria 
are concerned they are far too numerous to cause any surprise 
that we cannot assign them for the case of cholera: since, as I 
have shown in other parts of this essay, the same poison, at the 
same time, and in the same place, acting on different persons, 
produces, not merely fevers, remittent or intermittent, but lo- 
cal diseases of very different kinds, even to the simplest painful 
affection of a minute point in a nerve. 

And this, which I have thus reserved, is the great argument 
against the opinion just thrown out, and stated also in the essay- 
on Malaria, that there are different qualities of this substance 
capable of producing distinct diseases, or their actual causes. 
If one spot can produce every species of these disorders in dif- 
ferent individuals, the cause, it may be said, must be sought in 
the individual himself, not in the poison; or, that being the same 
for all cases, it is to influencing or collateral causes that we must 
attribute the specific forms or varieties of disease produced. 
The conclusion seems incontrovertible; and I am fully aware of 
the difficulty of maintaining the reverse opinion against this fact. 
And yet if that opinion is not, in some measure at least, well- 
founded, how are we to explain the familiar circumstances stated 
in the essay on Malaria, namely, that certain forms of fever are 
peculiar to certain places and countries, and that these differ- 
ences are often no less marked than they are constant? I must 
confess at least my own incapacity, with my own willingness to 
believe any thing, provided it be proved; while I think it best 
to state every difficulty and every contradiction, since where 
we do not know, the best proceeding always is to satisfy our- 
selves very clearly of our ignoranee. To return to the question 
of cholera. 

Certain analogies may also be produced to confirm what seems 
to be thus indicated; and it is perhaps obvious that I am about 
to allude to the case of inflammation of the liver, the produce, 
as I have elsewhere remarked, of the Malaria in certain coun- 
tries ; as in India and Africa notedly, and, if less remarkably, in 



DYSENTERV AND CHOLERA. 119 

the West Indies also. Here, the poison that might produce fe- 
ver, exerts a sole or a predominant influence on this gland, ge- 
nerating inflammation; as, in a different set of cases, it may af- 
fect muscles or membranes, and cause rheumatism. And if it 
can produce inflammation of the liver, it may equally produce 
cholera, since both are apparently increase of action, though in 
different sets of vessels: while that possibility is further con- 
firmed by other cases described in this book, where the action 
of Malaria on a glandular system is demonstrated in the produc- 
tion of diarrhea and diabetes, or where the febrile disease be- 
comes localized in this peculiar manner. 

Another analogy in confirmation of the same views, is found 
in the character of the remittent fevers called bilious, and very 
especially in those where the affections of this system form a 
conspicuous part of the disease. Such is, notedly, the usual 
fever of Walcheren, known in the country by the name of the 
gall disease; and such, I need not say, are the still more noted 
yellow fevers in many cases. In all such instances, though 
with various modifications, we may consider the disease as a fe- 
ver with cholera, or a mixture of the two, while as the one or 
the other may predominate, the character of the disorder or the 
ease varies. Or, with the general action on the nervous sys- 
tem, generating pure fever, there is a local one on the liver, 
productive of cholera; just as occurs with respect to dysentery, 
or as also happens in the much less serious disorders of this 
great class, where a Neuralgia may be accompanied by a per- 
fect and marked intermittent, or where that may be nearly in- 
sensible. Thus, to put extreme cases, we may conceive that in 
the simplest ordinary cholera, there is only the local affection, 
or the general one is so slender as to be unnoticeable; while, 
where a remittent is accompanied by the slenderest possible 
symptoms of affection of the liver, or becomes a moderate 
"bilious fever," we find a case the exact reverse. 

I shall not dwell on this subject longer: but such are the views 
respecting cholera which seem to me borne out by analogy and 
by direct evidence both; though willing to be corrected by dif- 
ferent views of facts, as far as such views may be founded on 
similar grounds; on real evidence, not on medical dogmas. The 
value of such a theory, as to the practice in this disease, may 
not indeed prove much; but it will always be advantageous to 
investigate the truth, and, if that can be done, to bring our sci- 
entific views of diseases into a more philosophical shape: be- 
sides which, should this view of the cause of cholera be the 
true one, we shall have made the same step as to its prevention 
as we have done in the case of fever and much more. This is 
at least a main object of the present inquiry, if it is not the 
principal one: it is that which was the chief inducement to write 



120 ON INTERMITTENT FEVERS. 

this brief chapter on a concatenated set of disorders which it 
was not my intention to discuss fully, and on the cure of which, 
well understood as it is, I do not propose to treat. My medi- 
cal readers will, I trust, not forget what the object of this book 
is: that its purpose, throughout, has been to explain, under new 
views, what appeared to me imperfectly known or misappre- 
hended; not to produce, and least of all to compile, an entire 
system respecting a class of diseases which, at some future day, 
will justify a new compilation in the hands of some s} r stematic 
writer. 



CHAPTER VI. 



On Intermittent Fevers. 






So much has been written respecting intermittents, and 3 
I may add, so well has this been done, that it may almost ap- 
pear presumptuous to meddle with that subject again. It is at 
least superfluous for me, in this place, to dwell on the more ob- 
%'ious forms of this class of fevers: but while I have undertaken 
to mark the more obscure and complicated cases, I cannot avoid 
entering on the whole subject, at least to a certain extent; trust- 
ing to my medical readers to supply from their own know- 
ledge and from the crowd of authors on this disease, w r hat I 
purposely omit that I may not unnecessarily prolong this work. 

Nor, even had it been superfluous to note the obscurer cases 
of intermittent, to record my own observations, and, still more, 
to repeat what may be found in authors, could I have avoided 
such an examination; since the whole of the local affections, 
which may be ranked under Neuralgia, so long and so general- 
ly misunderstood, are intimately connected with these, and 
since the proofs, as to their real nature, must be deduced from 
their connexion with such obscure intermittents. Thus also 
while, under the present view, it will be proved that many dis- 
orders which, generally, under the popular one, appear to be 
original and separate diseases, are but symptoms dependent on 
intermittent, as has already been shown in the case of remittent, 
I shall not only smooth the way for understanding these anoma- 
lous and troublesome disorders, but, further, explain much that 



ON INTERMITTENT FEVERS. 121 

must otherwise have found a place in a different part of this 
essay, and often in a less luminous manner or position. 

That intermittents, of whatever type, are the produce of Ma- 
laria, is a fact as universally established as any thing in medi- 
cine can well be; while, as 1 have formerly observed, it is by no 
means proved that there is any other cause, at least of the ori- 
ginal disease, or first attack, however such causes may have the 
power of re-exciting an intermittent where it has once existed. 

If I have already shown that it often follows remittent, when 
it may be considered as, in fact, the same disease, but with pa- 
roxysms and intervals differently arranged, so it is often a pri- 
mary disorder; or the first effect of Malaria is to produce an in- 
termittent of some type, and not a remittent. Arithmetically, 
it will further be found that this effect of Malaria predominates 
in the colder climates and the colder seasons of the year; or that 
while remittent rather than intermittent is the disease of hot 
climates, and of autumn or summer, the latter is most frequent 
in the colder climates and in spring. How far this variety of 
effect may depend on the quality or quantity of the poison, and 
how far on the conditions of the human body, I have already 
said all that I know, and all, I believe, that physicians appear 
to know on a very obscure subject. And having sufficiently 
noticed the manner in which it follows remittent fevers, I may 
now limit myself to the consideration of the primary or origi- 
nal disease. 

The attack of this class of fever seems, like that of remittent, 
to follow sometimes instantaneously on the application of the 
poison, while in others it is protracted to analogous distances in 
time; though I know not if physicians have fairly observed that 
it may be later than twent} T -four hours from the exposure to the 
cause. This is a difficult observation to make; but having al- 
ready discussed the subject as to remittent, I must leave it to 
others to attach that credit to authors, on this point, wherever 
they have supposed the interval longer, which they may seem 
to deserve. 

The attack, in the ordinary cases, is marked by what is called 
the cold fit; and the recurrence of this peculiar state indicates 
equally, if under many modifications, the commencement of 
each new paroxysm: or the whole disease is a succession of dis- 
tinct fevers, limited, each, to periods varying from an hour or 
two, to twenty or more, and separated by intervals of what is 
called health, imperfect as that may often be; conditions which 
are, at least most generally, not states of fever, be they what 
they may. The term cold fit, however, conveys a very imper- 
fect idea of the actual nature of this singular stage. There is a 
sense of coldness, it is true, and often excessive, attended also 
by shiverings in many cases, and sometimes so violent as a I- 

16 



122 ON INTERMITTENT FEVERS. 

most to amount to convulsions, attacking every muscle of the 
body, or occasionally limited to a few. But be the sense of cold 
what it may, it is very distinct to the patient's feelings from that 
which belongs to catarrh, or to the accession of any of the other 
diseases which commence in this manner: insomuch that patients 
suffering under chronic ague, can determine at once, by the pe- 
culiar feel, whether a cold fit is the recurrence of that disorder 
or the indication of another and a different one. It is not si- 
tuated in the skin alone, in this case, as it most commonly is in 
other cases of incipient disease, but appears to penetrate even 
the bones, and to occupy every fibre of the body; while it is ac- 
companied with an indescribable sense of universal pain, and of 
a fatigue resembling, but far exceeding, that which follows long- 
continued and excessive exertion; fatigue which no rest or po- 
sition diminishes, and which seems often to cause the greatest 
sufferings of the patient. With the cold fit also, there general- 
ly attends that distressing pain in the loins which belongs to all 
fevers, and which, from the very peculiar kind of suffering at- 
tending it, appears to have its seat in the numerous and large 
nerves of that region. 

Headach and unquenchable thirst are also frequent, symptoms 
of this stage; while so far from the temperature of the skin be- 
ing necessarily lowered, it is sometimes hot, while dry, to the 
touch, even when shrunk and pallid, though it is much more 
common for it to feel cold to the by-stander: in which cases the 
shrinking is extreme or almost approaching to lividness, as if 
from the effects of external cold. Thus also, yawning often at- 
tends the cold stage; and sometimes to such a degree of irrepres- 
sible violence, as to threaten the dislocation of the jaw; as spasms 
in the muscles of the throat produce involuntary sounds, which 
a by-stander often supposes to be the produce of feebleness of 
mind. In this stage, the pulse is generally contracted, hard, 
and accelerated, in different degrees; and not unfrequently this 
state precedes, when watched, the sense of cold and shivering, 
or is the immediate warning of the cold fit. 

It is to this stage also, that the comatose state so common in 
intermittent belongs: frequently present, though in different de- 
grees, sometimes producing short fits of painful sleep and more 
painful waking, and, in certain cases, so profound as to resem- 
ble apoplexy. I already noticed this circumstance as marking 
the first attack of the remittent fever, in Italy notedly; and 
while it occurs similarly on the attack of intermittent, so it of- 
ten, even in the chronic disease, is the sole apparent cold fit, or 
takes occasionally the place of the more regular attack. As I 
shall hereafter show, and have indeed already pointed out, it is 
a most important variation to notice, from the dangerous errors 
in practice to which it leads. Of other accessary symptoms. 



ON INTERMITTENT FEVERS. 123 

the only one requiring notice at present, is the increased secre- 
tion of urine. 

When death is produced by intermittent fever, it sometimes 
happens in the cold stage, though it is in quartans chiefly that 
it occurs at this period; being apparently the produce of the 
same action, whatever that is, which causes the apoplectic symp- 
toms. In other types, and consequently in the great majority 
of fevers, it is the hot stage which is the period and the appar- 
ently immediate cause of death. The duration of this state is 
extremely uncertain; since it may terminate in almost a few 
minutes, or last many hours; while the severity of the paroxysm, 
as of the entire disease, is generally proportional to that of the 
cold fit, In the perfect form of the disorder, it terminates in 
the hot stage. In this, the sense of cold is succeeded by that of 
burning and dry heat, of which the indications are sensible in 
the feel of the skin, and by thirst aggravated, with continuance 
or aggravation of the headach; or, as sometimes happens, the 
headach and the thirst commence with the hot fit. If the sense 
of fatigue diminishes or disappears, the pain of the loins com- 
monly continues, while the pulse becomes generally freer, though 
still continuing rapid and full. 

In severe cases, delirium occurs, or is a substitute for the coma 
of the previous stage; but painful as the hot fit may be in all the 
ways that fever is distressing, it is very commonly a relief from 
the much greater severity of the cold one, if that at least has 
been long. Anxiety of the praecordia, the common symptom 
of all fevers, also frequently attends this stage, as it does the for- 
mer; sometimes with more decided affection of the heart than 
that which had preceded, and also with spasms, apparently in 
the larynx, or throughout the pulmonary system, producing a 
distress often amounting to the sense of imminent death. This 
affection, when remarkable in proportion to the other symp- 
toms, seems to approach to that variety of the disease to which 
the term "asthmatic," is given by nosological writers; however, 
that peculiar modification may sometimes be of a much more de- 
cided and distinct character. The painful restlessness so com- 
mon in fevers, also belongs chiefly to this stage; and in slighter 
cases, is sometimes even the symptom which attracts most of 
the patient's attention, or may cause the chief suffering. The 
duration of the hot stage is, like that of the cold one, very un- 
certain, as it may equal, or exceed, or fall short of it; while 
cases occur in which the former occupies a large proportion of 
the whole fever, or is almost the only very striking part of it; 
as, on the other hand, the cold one may acquire a similar pre- 
dominance. Let the disease be modified as it may, it would 
not be very easy to point out one which condenses into so short 
a space a greater quantity and variety of suffering: while, to a 



124 ON INTERMITTENT FEVERS. 

spectator, it may appear but a small evil, to be cold, and hot af- 
terwards, for a succession of hours, such is the effect of the com- 
mon ideas attached to those two terms, while so very little do 
those terms express the facts. 

In the regular disease, the hot fit terminates like the cold one? 
after a certain time, and is succeeded by a relaxation of all the 
symptoms. The pulse becomes fuller and softer, and more na- 
tural in every way, the pains and the thirst disappear, and a 
perspiration occurs, often extremely profuse; at the termination 
of which the patient is free from obvious disease, however en- 
feebled he may remain. It is a critical solution of a fever; and 
is a miniature, in point of time at least, of what sometimes oc- 
curs in the fevers of longer durations It is not unusual how- 
ever for nausea, or vomiting, to come on before the period of 
fever is finished; and far most generally in the cold fit, which 
it sometimes terminates: and, as I shall hereafter show more 
particularly, when this symptom is conspicuous compared to 
the others, there is produced a variety to which the term Eme- 
tica has been. applied. 

It only remains to notice the state of the mind during the fit 
of intermittent; and it is chiefly important on account of its ef- 
fects on the conduct or feelings of the patient, in those cases 
where the bodily symptoms are less striking, or in the very ob- 
scure or milder disorders of this nature, whether chronic or 
otherwise, in which this appears to the by-standers almost the 
only disease. To judge correctly respecting its cause, is most ne- 
cessary; as well for the sake of the moral judgments that may be 
formed as to the patient, and for his consequent comfort, as for 
the self-regulation of his own mind and conduct. If these re- 
marks concern rather the chronic and milder diseases than the 
acute one, in which the visible severity of the fever seems to 
justify or excuse moral aberrations, it would be inconvenient to 
divide them, while it is necessary to mention the facts here. 

If the state of the mind in intermittent resembles that which 
occurs in the remittent fever, already described, it seems to suf- 
fer more generally and more severely from irritability, while 
the existence of this condition in chronic cases, when scarcely 
any other symptoms are very conspicuous, or when habit has 
almost reconciled the patient to them, never to be reconciled 
to this, renders it especially worthy of remark. This state of 
feeling attends the cold fit especially; and hence it is that it is 
more common in intermittent than in remittent: while, as it is 
often coupled with feelings of inexplicable misery and despair, 
and with false views of every thing, it produces those often for- 
midable, and always distressing consequences which are so com- 
mon in this disorder. And if, as a portion of the cold fit, it ge- 
nerally subsides with that, or disappears during the interval^ it 



ON INTERMITTENT FEVERS. 125 

is, sometimes, the only, or almost the only symptom attracting 
the attention, either of the patient himself or his circle. It is, 
in fact, at times, the sole cold fit, or almost the only disease; 
though a watchful eye may always discover that it is connected 
with that collapse of features or change of expression which at- 
tends every cold fit of intermittent, and, very commonly, with 
that peculiar physiognomy, easier recognised than explained, 
which, to an observant eye, is always sufficient to indicate every 
disease, general or local, connected with intermittent, or arising 
from Malaria; an appearance which, when more strongly marked 
in the pallid hue of the face and the shrinking of the nose, ought 
to decide the question, even to the most negligent observer. 

Of its true nature and cause, be the moral results what they 
may, no doubt can be entertained, because of the suddenness of 
the attack and of its periodical character; and it thus happens 
that almost in a second of time, and even in the midst of active 
good humour, or passive feelings of comfort or happiness, the 
fit of ill temper, or irritability, or despair, of a moral change 
under modes too various to detail, will occur, to last as long as 
the cold fit would have lasted had it been present; or lasting, 
when that is visible, just as long as the duration of the peculiar 
physiognomy which I have described. To be aware of this fact 
and this cause, on the part of the patient's circle, is to be fur- 
nished with reasons for making that charitable excuse which is 
seldom made, if ever, for what self-control might be supposed 
capable of preventing, and perhaps not much oftener for what 
is unavoidable; so rare is this species of charity: for the patient 
to be aware, himself, of the cause, is to furnish him with a guide 
for his own conduct in these circumstances, and a check over 
the display of those feelings; while it is also to offer him the 
consolation of knowing that it is his body rather than his mind 
which is diseased; that his perverted temper is not a moral and 
voluntary fault or failing; but as involuntary as it is capable of 
being remedied. I need scarcely say how easy it is for igno- 
rance and intolerance, the intolerance of good health, and some- 
times of what is not so pardonable, to combine the peculiar 
physiognomy of this disorder with its peculiar effect on the mind, 
and thus to suppose that the moral disease has affected the phy- 
siognomy, confirming the erroneous judgment; when both are 
the parallel and independent effects of a third and inevitable 
cause. Nor need I repeat, how, as in remittent fever, such a 
disorder of mind, ill observed, is mistaken for hypochondriasm; 
as is also a very common case. 

I have here described the milder moral derangements in the 
milder and chronic intermittents; but in severe cases of both, 
the united state of irritability and despair is apt to produce the 
far more serious effects of stimulating the patient, at least to 



126 ON INTERMITTENT FEVERS. 

think of suicide. This insane desire is a very common com- 
plaint of patients labouring under intermittent, and a very fre- 
quent source of great alarm and horror; while it occurs equally 
in patients who, before that, were cheerful, as well asyouthful ? 
in the female sex as in the male, in persons where, either from 
previous knowledge of their opinions and characters or from 
observation in the absence of the fit, we are quite sure that it 
cannot depend on a wrong state of mind or of opinions, but is 
as rigidly a portion of the disease as it is found to be a periodi- 
cal one. And if in many cases, patients even of this unsus- 
pected character, have desired that windows should be screwed 
down, that no edge tools should remain within reach, and so on ? 
it is to be suspected that actual suicide, occurring as it does so 
often without any apparent moral motive, has been the result, 
in other characters, or in severer states of the disease, or in cases 
where a peculiar facility has been united to this morbid and ac- 
cidental temptation. It is not often indeed that patients will 
confess this feeling to their physicians, far less to their friends; 
being unaware of the cause themselves, and dreading naturally 
the censure that would follow; but the physician who has not 
met numerous cases of this nature, must either be very unob- 
servant, or ignorant of the real disease under his eye, or else 
unfortunate in not acquiring the confidence of his patient. 

How important it is that the patient, and the friends equally, 
should be aware of this moral effect of intermittent, and of the 
real causes, it is far too obvious to point out; and this explana- 
tion will, in particular, be a great relief to the minds of those 
who, under these circumstances, have been haunted, for even 
years, with this species of frenzy or alienation of mind; since 
it will be to relieve them from fears respecting their moral con- 
dition, so painful as to be generally concealed with the greatest 
care: while, by holding out its real nature, and also the prospects 
of a cure, it will operate as a preventive to such rash conduct. 
It is well known that the desire for suicide is often exceedingly 
temporary, even when it is most overpowering; and I remarked 
formerly, when treating of remittent, that if controlled with 
resolution, for even a short time, it will pass away. 

That such cases are often, very often, connected with the dis- 
ease in question, I entertain very little doubt; and it were to be 
wished that this could be more generally known and believed 
than it is ever likely to be from all that I have here written. I 
need only add in this place, what I formerly indeed pointed out 
slightly, that as all modifications of delirium are increased by 
the solitude and silence of night, so does this desire for suicide 
become strongest in those circumstances, should night chance to 
be the period in which this fit occurs. If I have known a man 
high in intellect as in rank, a general officer who had brought 



ON INTERMITTENT FEVERS. 127 

this disease from Spain, enter his mother's bed in the night, in 
this state or agony of mind, it is not difficult to understand how 
it may have led to actions of similar aberration and far other 
consequences. Such, as I formerly suggested, is the probable 
explanation of a noted murder which I then quoted: while it is 
abundantly easy to see how the presence of the passion of an- 
ger rather than that of fear, as in the case just noticed, might 
tend to murder, as the other would have produced suicide. 

There is another mark yet, which it may be worth while to 
make on this mental disease, whether or not it is really connect- 
ed with intermittent in all cases. I have clearly ascertained it 
to be so, at least in some; or rather, every instance of the desire 
or attempt in question under this peculiar variation, which has 
come under my knowledge, has been a case under intermittent. 
As relates to the desire, the simple fact is, that the patient feels 
a species of antipathy against some peculiar part of his body ? 
added to the general disordered feeling, or he longs to commit 
the act by wounding that particular point; while, whether his 
aberration amounts to the desire of suicide or not, this very 
point or place is the one eternally forcing itself on his imagina- 
tion as an object of hatred and revenge. And so perfectly in- 
sane is this feeling, that I have been informed by more than one 
patient who has suffered from it, that there is no conviction at 
the same time that death would follow; or rather that the im- 
pression is as if the offending part could be exterminated or 
cured by the injury, and that the patient would then be well. 
And that suicide has actually been committed under this parti- 
cular aberration, is well known from the more curious records 
of physic; while I need not do more than suggest one peculiar 
part of the body which has been often the offending and se- 
lected point; the act having been sometimes also, but not always, 
followed by death. Nor has the motive always been a religious 
one in this case: and even when that may have happened, I be- 
lieve the fact to have generally been, that the corporeal feeling, 
with local antipathy, precedes; exciting by an obvious associa- 
tion, that peculiar false reasoning coupled with religion, which 
appears, reversely, to be the cause of the particular antipathy; 
and the more easily if religious fear or anxiety chances to be a 
ruling passion. How this may happen, metaphysicians will be 
immediately aware. The bodily sensation is one that has been 
accustomed to excite mental associations; while, by a natural 
and common reversal of the order of the train of thought, 
the mental feeling becomes the apparently primary one, and 
the cause of what follows, in an order that I need not explain 
further. 

To shorten a curious subject on which it would be abundant- 
ly easy to dilate, and to omit examples; some of which must be 



128 ON INTERMITTENT FEVERS. 

well known to medical readers, and one of which cannot be re- 
collected without some regret, by most persons, the philosophy 
of this, as far as my opportunities of observation have gone, 
and on the indicated ground of explanation, for these cases at 
least, is, that while the irritable, or jointly despairing and raging 
or angry state of this chronic fever is present, there is also a 
particular part of the body affected by an uneasy but undefina- 
ble sensation; such that the mind constantly reverts to it as a 
source of suffering. And if this local affection is not a Neu- 
ralgia, or a condition of absolute pain, yet it is a local and ner- 
vous one of an analogous nature, always returning to that one 
point under the same stage of the fever or delirium. When, as 
is not unusual, it is seated in the head, it is even distinguisha- 
ble by a dull pain, or a confusion, or a sense of " buzzing'' (for 
thus it is described by patients,) in one fixed place, indicating 
pretty clearly its real nature: while, in that particular case, I 
have the assurance of such patients, that the suicidal desire is 
exclusively directed to that individual spot, and that while a 
pistol would be the only acceptable mode, there would also be 
no satisfaction unless that were directed to this actual and only 
point. But I will cease, and allow physicians to exert on this 
solution of no easy question, the ingenuity which has not hi- 
therto succeeded in producing an intelligible explanation. 

Such is a general description of one paroxysm of the intermit- 
tent, or of a single fever. I have meant it to be but general, and 
as representing the more ordinary average of cases that occur 
in our own country; while if it is nevertheless long, it is that I 
wished to detail, as an observer, some particulars which have 
not been described, and others which, in the ordinary modes of 
describing this disease, do not make a sufficient impression on 
readers; and also, to dwell especially on certain points, the in- 
terest of which belongs to the obscurer cases rather than to the 
simple, acute, and highly-marked disorder. 

Let me however, even in incurring some repetition, describe 
a perfect, I had almost said the ideal and abstract form of a pa- 
roxysm of intermittent, that I may not be accused of too far 
abandoning the ordinary practice of medical writers. The com- 
mencement is marked by weakness, weariness, restlessness, in- 
describable uneasiness, melancholy, depression, or fear, and ge- 
nerally, yawning, often extremely violent. The skin feels cold 
to the touch before the patient is sensible of coldness; and it is 
then pale, or puts on the goose-skin appearance; the face, and 
chiefly the nose, assuming also a very peculiar aspect of shrink- 
ing and subsidence, with the air of misery; and often becoming, 
further, of a greenish yellow, or a clayey tinge, or even of a livid 
hue. The feet first become cold, when the trembling follows; 
but the coldness may be partial or general, while a sense of in- 



ON INTERMITTENT FEVERS. 129 

ternal heat is often felt; the skin also becoming hot to the touch 
towards the end of the cold stage, while the patient still suffers 
under the sense of coldness. 

In this stage, the pulse is small, frequent, irregular, and, some- 
times, not to be felt at all: the breathing is frequent and anxious, 
and there is sometimes cough, often sighing, with tightness and 
oppression about the prsecordia. Stupor or coma is not unfre- 
quent, but there is rarely any delirium till the hot fit: and with 
that, there is numbness, together with a diminution or loss of 
the sight and hearing. Pains of the limbs, and chiefly of the 
back, also accompany, with shrinking of the skin and extremi- 
ties, often attended by the drying up of ulcers and the subsi- 
dence of tumours, should those be present; and violent thirst 
never fails to take place. If nausea and vomiting occur in the 
hot stage, they chiefly belong to this one, happening, particular- 
ly should the liver be affected; and the evacuation in this way, 
of bile, sometimes a similar purging also, is the consequence. 

Such is the cold stage when extreme, lasting from minutes 
even to many hours, but most short as the paroxysms are more 
approximated or the fever most severe. The hot fit follows, 
and immediately after the vomiting, should this have occurred. 
The skin now swells, and the features enlarge; the temperature 
rising sometimes as high as 105, with a burning sense of heat 
to the touch as to the patient himself. The pulse becomes strong 
and full, increasing also in velocity, to even 120 and upwards; 
the sensibility, to noise and light especially, is increased, and 
even the senses of taste and smell become often unusually dis- 
criminating. Sometimes, but not always, the breathing is re- 
lieved; the oppression indeed is, on the contrary, often materi- 
ally augmented: the headach, which I neglected to notice in the 
cold fit, is aggravated, and delirium comes on, with great in- 
crease, if that be possible, of the thirst; and the urine, which 
had been abundant and limpid, diminishes and becomes high 
coloured. Sometimes the nausea goes off, but that is not inva- 
riable; while even vomiting sometimes happens, and the occa- 
sional occurrence of hemorrhages, commonly slight, completes 
this catalogue. With the sweat, which follows, the pulse abates, 
the urine deposites a red sediment, the patient generally falls 
asleep, and the paroxysm terminates, leaving behind it debility 
varying in degree according to the character of the disease. I 
need only add, that according to some authors, there is in the 
sweat, a peculiar indescribable odour, which I do not however 
profess to have discerned; and that according to Strack, this is 
so remarkable, as even to form a criterion of the disorder in 
those obscure and anomalous cases which might otherwise, from 
the prevalence of peculiar symptoms, be confounded with some 
other original disease. 

17 



130 ON INTERMITTENT FEVERS. 

Such is a perfect or abstract picture of the intermittent pa* 
roxysm, cleared also from every occasional or supernumerary 
symptom which belongs to peculiar epidemics, or peculiar va- 
rieties, such as, those which are accompanied by inflammations 
of various kinds, by extreme affections of the liver or the brain, 
by what are called malignant symptoms, such as are petechias,, 
by peculiar nervous affections, or by those several appearances 
or additional diseases which I have described under the head of 
anomalous intermittent. Among these, it must especially not 
be forgotten, though I have not thought it here necessary to 
treat of those severe kinds, preferring a reference to authors, as 
I have done in the case of remittent of similar characters, that 
among the malignant epidemics, pure intermittents, even tertian 
or quartan, are not uncommon, though unknown to our own cli- 
mate; and that, like the remitting or continuous or marsh fever, 
these kinds occur in .autumn. I urge this, that I may not be 
supposed to have forgotten what I do not think it necessary to 
describe; having here limited myself to what alone I have seen 
and to what England sees alone. When a tertian is fatal in the 
second or third paroxysm, it is evidently a disorder with which, 
at least as an epidemic, we are unacquainted: and with respect 
to the treatment as to the history of such epidemics, there is, 
as in the case of remittent, no want of accurate and valuable in- 
formation. 

But independently of this, and while with us also, the inter- 
mittent paroxysm is rarely so extreme as I have here represented 
it, there are numerous variations in its course and character, of 
which I must notice a few among the most conspicuous, even 
now: though such irregularities must come under review in the 
account of the chronic and anomalous varieties, where they are 
much more frequent and more necessary to be known. 

Thus, the cold stage, or the hot, or the sweating one, may be 
absent, as may any two of them; or the hot stage may appear 
before the cold one, or there may be repeated alternations of 
heat and cold, as in remittent, or, not to enter into further mi- 
nutiae, the whole may be a scene of confusion. In some rare 
cases, the entire fever, or any portion of it, is partial; or, one 
part of the body, even to a limb, may undergo a regular or an 
irregular paroxysm. 

In quotidian, resembling remittent as it does in so many 
points, the cold stage is shortest; and, reversely, it is longest in 
quartan; but the entire paroxysm is longest in the first, and 
shortest in the last; tertian, in both respects, holding an inter- 
mediate course. It is a general observation among authors, that 
the attacks of intermitting fevers are, in the proportion of nine 
to ten, more frequent in the day than in the night, and that the 
period from eight to eight will generally be found to comprise 



ON INTERMITTENT FEVERS. 131 

all those which last less than thirteen hours. The remark is, I 
believe, sufficiently true as to acute or recent fevers of this na- 
ture: but it is far less so as relates to the chronic or relapsing 
ones, and, as I have here remarked in another place, is not an 
unfrequent accessary cause of errors, often of no small mo- 
ment. 

With respect to the duration of a paroxysm, should it occu- 
py the whole twenty-four hours, or should the intermission be 
ill marked, it becomes a remittent; in which case also, as in all 
quotidian or diurnal intermittents, the cold fit bears a small pro- 
portion to the other parts of the paroxysm. A perfect inter- 
mission constitutes it a quotidian; and this variety therefore con- 
sists in one diurnal paroxysm with one complete interval of 
health, or of freedom from actual fever. Such is the simplest 
type of intermittent; a quotidian ague; while in the variety of 
the times of recurrence, we find the other types of this dis- 
ease. 

There can be no reason to doubt that intermittent and remit- 
tent are but modifications of one disease, and equally, that the 
same poison produces both, even in the same individual spot, 
modified perhaps in quality, or else acting differently in conse- 
quence of differences in the quantity. It is a mild fever or a 
severe fever: mild when vegetation and putrefaction are least 
active, as in spring, and severe when the reverse occurs after 
the heats of summer. And thus it sometimes happens, that 
while, on certain occasions, the spring disorders entirely disap- 
pear, leaving the solstice free of disease, when the autumnal 
ones succeed, in other cases, according to circumstances in the 
season, there is no interruption; while it has even happened in 
England, as I once before remarked, that the remittent has ap- 
peared in spring and proceeded throughout the whole summer. 
I speak here of our own country; because in the hotter climates, 
original and vernal intermittent is comparatively little known; 
the epidemics, even from their commencement, being of the re- 
mittent character. 

Thus, and for obvious reasons, it is also a general rule, that 
the vernal diseases, being intermittents or otherwise, are more 
inflammatory; while the fevers of autumn are more generally 
malignant, or have the characters attending debility, together 
also with a greater predominance of bilious affections. And if 
we proceed along the season in the same manner, we shall find 
that while remittents continue in their proper form during the 
hot weather, they begin to intermit, even in hot climates, on the 
setting in of the cold. A natural conclusion which follows this, 
is, that be the power or effect of Malaria what it may, or how- 
ever its production may be regulated by the state of tempera- 
ture and the corresponding conditions of vegetation, there is, in 



132 ON INTERMITTENT FEVERS. 

the mere action itself of heat on the body, an accessary cause 
which is of considerable effect in determining the form and cha- 
racter of marsh fever. The well-known rarity of simple and 
original intermittents near the equator, must therefore be sup- 
posed to depend on these different circumstances combined. 
That, of the different types, quotidian and tertian are the gene- 
ral intermittents of spring, and quartans those of autumn, is a 
remark as old as physic itself. 

If it is a rarer case, it also occurs that two distinct parox- 
ysms take place in one period of twenty-four hours, constituting 
a double quotidian; while if, with respect to this variety, it some- 
times happens that one paroxysm belongs to the night and the 
other to the day, there is a similar tendency to that which I just 
remarked of intermittents in general, namely, to bring as much 
of both the fevers as possible within the hours of day. When 
the parox}^sm occurs but once in the period of forty-eight hours, 
the type is tertian, while the same occurrence in seventy-two 
hours produces quartan; beyond which it does not appear that 
any regular single type has been often found, though, as I shall 
presently show, such peculiar cases do occasionally happen. In 
the tertian, obviously, one period of twenty-four hours is free 
from disease; while, in fact, there is generally much more, as 
the paroxysm scarcely ever occupies its own twenty-four; and 
thus the quartan also leaves two days of health. Hence it is, 
that if these types, and the latter in particular, are the most du- 
rable, or tend most commonly to the chronic state, they are the 
least inconvenient, as they do not entirely disable the patient. 
Hence it is, that in so many parts of France and Italy, the bu- 
siness of life is conducted, and in some places almost solely, by 
a population of which the far greater number, and sometimes 
the whole, are labouring, and even through life, under these 
chronic agues. 

Particular cases of types extending beyond these, are, as I 
have just noticed, to be found in authors; but, as rare instances, 
they are objects of curiosity rather than of use. The most un- 
expected one that has occurred to myself was one of a quotidian 
attack, recurring three successive days, but interrupted by in- 
tervals of six weeks, and thus lasting for some years; and from 
this case it will be easy to conjecture how many strange modi- 
fications of intermittent may exist. 

Boerhaave, Van Swieten, and others besides Galen long ago, 
describe a quintan' type; while some speak even of regular re- 
currences as distant as the fifteenth day. In some authors, we 
find accounts of intermittents occurring once a month, once in 
two months, and so on; while, where others speak of annual 
types, it is abundantly plain that this is a mere perversion of 
terms. For such histories, De Haen, Sauvages, the author? 



ON INTERMITTENT FEVERS. 133 

named above, and many more, may be consulted; while their 
Erraticse are the chronic and irregular diseases which I have 
here noticed very fully. As to the endless terms by which the 
older authors have distinguished varieties in these fevers, such 
as amphimerina, epialis, syncopalis, hemitritaeus, subintrans, 
and so forth, they are as useless as they are idle refinements or 
superfluous and trifling distinctions: but he who, following Sy- 
denham, may feel any affection for them, may easily store him- 
self out of Sauvages. Of the distinctions grounded on anoma- 
lies, however, I must speak with respect; because they are of 
considerable value in calling the attention to the obscure and 
simulating cases; and I have- here accordingly noticed them 
wherever that appeared to be proper. As to the quotidian type, 
I should add in this place, though compelled to notice it when 
speaking of remittent, that its existence has been denied by 
some authors. It is probably true, that, in the hotter climates, 
quotidian, perfectly distinguishable from remittent, is rare; and 
we must conceive that the authors of this opinion have drawn 
their conclusions from such countries, since the existence of 
well-marked quotidian in our own can admit of no doubt. 
Otherwise, it may be a mere dispute of terms; some physicians 
considering as a highly-marked remittent what others would call 
a quotidian. 

But there are fevers also of double type, which, coming un- 
der some general law, however obscure that may be, are more 
deserving of notice than the protracted one just named. The 
most common and the best marked of these, is the double ter- 
tian; the existence of which can admit of no dispute; while I 
shall soon show that it is one of those types frequently connect- 
ed with the local diseases, confirming the views respecting these 
which I have held out. If this type may sometimes be con- 
founded with quotidian, as it also is at times so little distinguish- 
able, when chronic, from remittent, that I have hesitated about 
the proper place of many of these diseases, the distinction may 
commonly be made, with due attention. Either the two con- 
secutive fits do not recur at the same hour, or they differ in 
strength, or in duration, or the several parts of the paroxysm 
are differently apportioned, or a particular symptom attends the 
one which does not accompany the other. If I have read of 
combinations of tertian and quartan, of triple quartans, and of 
others that may be imagined, I have no experience in them, and 
shall, as formerly, for their descriptions, prefer a reference to 
the authors by whom they are described; as they do not appear 
to throw any useful light on the nature of these singular diseases. 
It may be an object of curiosity however barely to notice some 
of these: but the warranty for such types must rest with those 



134 ON INTERMITTENT FEVERS. 

by whom they have been observed, and it is indeed probable, 
that in our own country, at the present day, it would not be 
very easy to produce many examples deviating from the more 
ordinary forms. 

The ordinary double tertian, as I have seen it, is marked by 
a daily paroxysm; but with the characters, on any two succeed- 
ing days, so different, as to convey the impression that there 
are present two distinct tertian fevers, the one of which had ori- 
ginally commenced on a given day and the other on the suc- 
ceeding one. But in the other variety, two paroxysms occur 
on one day, and there is an intermediate one free from disorder., 
In that which has been called a triple tertian, there are two pa- 
roxysms on one day and one on the intermediate; as if three 
distinct fevers had been brought within the space of two days. 
In the double quartan, as in the double tertian, there are also 
two varieties noticed. In the first, two paroxysms occur on one 
day, to be reckoned the first, leaving two intermediate days 
free, and the fourth day containing also two paroxysms: while, 
in the second, there is a paroxysm on the first, on the second, 
and on the fourth day; the third being a day of repose. The 
triple quartan is described as having, in its first variety, three 
paroxysms on the first and three on the fourth day, only; and, 
in its second, a paroxysm on every day, so arranged, that the 
first and fourth, commencing from any one of the three days, 
always correspond in character. 

If, in speaking of the chronic remittent, I have placed under 
that disease, many febrile disorders or states which have hither- 
to not been so explained, and at the hazard, as I conjecture, of 
no small criticism and opposition, I am not yet courageous 
enough to state my own conviction that intermittent fever may 
consist of but one paroxysm, finding also its own natural ter- 
mination after one attack; and consequently, that the fever 
called ephemera is, in reality, often a single intermittent.* Yet 
such is the decision of Strack, whose experience in this disor- 
der seems to have been equalled by his attention to it, and who 
is not to be lightly doubted. And from his observation, this is 
the disease which terminates in an eruption on the lips; while 
the reason for believing that this view is a correct one, is, that 
in the intermittent, such an eruption does terminate the disease 
after any number of paroxysms, and that the returns are often 
perfectly regular. It is always difficult to be certain that we 
can safely refer to Hippocrates for support, such is his brevity, 
and too often his obscurity: but if his testimony as to an inter- 
mittent fever which terminates by ulcerations of the lips is here 
applicable, the authority may add to the weight of the evidence 
on this point. 



ON INTERMITTENT FEVERS. 135 

It remains to notice what is called anticipation and postpone- 
ment, and also change of type, as parts of the necessary history 
of intermittent. 

In the anticipation of paroxysms, the hour of attack becomes 
earlier, as in the postponement it becomes later; the former be- 
ing generally esteemed to mark the aggravation, and the other 
the diminution of the disease. These states, however, belong 
principally to the terminable or limited intermittents; as, in the 
chronic ones, the periods are generally remarkable constant, 
even for a long course of years. And from an analogous pro- 
cedure, as remittents terminate in quotidian intermittents, so do 
these latter sometimes settle into tertians. And, further, if ter- 
tians change into quartans, or even into more complicated types, 
such as the triple quartan, so do they reversely, become quoti- 
dians, and even remittents; while I must observe that changes 
in this direction, being the approximation or aggravation of pa- 
roxysms, are the very general proofs of a severe and dangerous 
disease, occurring chiefly in bad seasons and climates. 

It is an old notion that vernal agues at least are salutary, nor 
is it by any means out of date among the common people in 
our own country. That they purify the blood, remove chronic 
diseases, and lead to old age, was even the opinion of Boer- 
haave, as it was not less entertained by the noted physicians of 
our own island, whose names have at length become great names 
in physic. It cannot be very easy to discover how an opinion 
like this should have found such supporters: except that where 
an intermittent may have appeared to remove a chronic disease, 
it has, not improbably, been one of those cases hereafter 
pointed out, where a simulating one had become simple and re- 
gular. 

I must also add here a remark on one effect of intermittents 
for which I could not conveniently find another place, while it 
is also connected with the opinions in question, inasmuch as it 
has not improbably given rise to them. It is the tendency 
which they often produce in patients to become fat, as is well 
known in Flanders especially, it is said. This happens after 
acute cases or single attacks; even when there is no suspicion of 
organic disease: nor indeed is the obesity confined to the omen- 
tum, or abdomen; the whole person enlarging, and often with 
surprising rapidity. And what is remarkable, this occurs also 
in the most obstinate chronic cases, and even when the presence 
of diseased spleen is proved; while even the daily occurrence of 
fits does not check that tendency, unless the febrile state should 
be very strongly marked. And in such cases also, it will fre- 
quently happen that while a period of unusual severity, or a new- 
relapse produces emaciation, the patient recovers his usual su- 
perfluous bulk, within a week or two, even though the chronic 



136 ON INTERMITTENT FEVERS, 

and slighter disease is going on. Whatever be the explanation, 
it is a fact from which we might perhaps argue that the consti- 
tution suffers little serious injury from the disease, though in all 
such instances the loss of muscular power is generally very con- 
siderable. How often emaciation, on the other hand, is pro- 
duced in such cases as are every where seen in the unhealthy 
districts of France and Italy, where serious organic disease is 
present, it would be superfluous to say. And though I for- 
merly remarked, from French authority, that such obesity was 
not of a healthy or firm nature, while it is even asserted that a 
portion of this unnatural bulk consists of water, it does not by 
any means appear that this is the opinion in Flanders and Hol- 
land. 

It is unnecessary to detail further the history of intermittents 
in their most simple, marked, and ordinary form; and I must 
now therefore describe the chronic state; not merely because of 
its own intrinsic importance as a frequent cause of great suffer- 
ing, but because it is under this mode that the greater number 
of the anomalous and simulating cases occur. 

Any type of intermittent may become chronic, and any type 
may also become durable; though it is a general observation 
that the quartan is the most enduring, and that it also is the one 
which proceeds longest with the least interruption. It is not 
rare that a quartan should last even to twenty years, or through 
life, be tl at what it may. I know not comparatively, what 
may be the duration of the other types, as it would be an al- 
most impracticable labour to extract it from the records of cases; 
but it seems ascertained, that after the quartan, the tertian is, of 
the simple types, that which lasts the longest. 

If any type may thus become chronic or durable, I must also 
remind the reader of the resemblance between the chronic or 
repeating remittent and the intermittents of a quotidian and dou- 
ble tertian type. I do not know, at the same time, how far the 
quartan may be interrupted by long intervals of health, or ab- 
sence of fever; as our experience in this country respecting that 
type is very limited, and as it is not easy to discover the exact 
truth from the writings of authors. But in the other types, 
while the disease is still chronic, it is often interrupted; or there 
are successions of distinct intermittents of the same character, 
separated by intervals more or less durable of health, as hap- 
pens in the chronic or repeating remittent. 

Such is a general view of the character of this set of diseases; 
while, with respect to the progress, though the general type, 
and even the hours of recurrence may remain the same, during 
years, and at whatever distance of return or length of interval, 
it will frequently happen that the strength or energy of the se- 
parate returns vary, or that the local symptoms which existed 



ON INTERMITTENT FEVERS. I 37 

In one recurrence, may be absent in another. And thus also, 
when the disease finally disappears, it is generally in conse- 
quence of, or in sequence to, a gradual diminution of the energy 
or length of the successive recurrences. 

Further, with respect to such recurrences, and chiefly in the 
most ancient or enduring cases, there is often a great irregula- 
rity in the lengths or energy of these. Any one may be se- 
vere, and may be protracted even for months; while a subse- 
quent, or perhaps a next one, may not extend beyond a few 
days, or even one fit, or may be so slight as scarcely to be dis- 
coverable by any one but the patient himself, whose attention 
habit has sharpened as to this subject. And thus, further, it 
may happen that the possessors of a chronic ague have arrived 
at such a state, that no traces of the disease remain but a suscep- 
tibility of recurrence on slight causes, while the paroxyms thus 
produced almost terminate with the exciting circumstances. And 
here also we see distinctly the necessity of avoiding them; above 
all, the caution requisite respecting Malaria, and the advantage 
of studying carefully all those circumstances under which that 
may be generated or conveyed. As in quartan, the length of 
time through which this state may last seems indefinite; and where 
the patient continues exposed to the great exciting cause, or to 
reside in a land of Malaria, any one of them may be the inheri- 
tance of life; such as life is, in those cases and those countries. 

Still, it is necessary to state on the other hand, that in some 
countries, as in French Flanders for example, it is remarked 
that while these fevers terminate of themselves, with the season 
that produced them, recurring however again in the same sea- 
sons, perhaps for two or three years, it is not uncommon, for 
children particularly, to become seasoned to the climate as it 
were, and to suffer no further, unless however they are re-ex- 
posed to the more active exciting causes. And thus also in 
other cases and countries, just as happens in the remittent, do 
persons become seasoned to intermittent, as it is commonly con- 
sidered; or, after recovery from a severe attack, they become un- 
susceptible of fresh ones, or of attacks of similar severity. This 
is the very singular history of West Indian fevers, in the divi- 
sion of remittents, as formerly discussed; while what was there 
said applies in a great measure to the case now under examina- 
tion. In the pernicious districts of Italy, Sicily, and France, it 
is also not unfrequent for the people to become, as it were, cal- 
lous to intermittent, or at least to severe attacks or severe re- 
newals, though the existence of the disorder in a chronic state 
may still be often traced; while, as far as we can judge from 
that mass of reports for which we must trust to some bad obser- 
vers as well as to the better ones, this effect appears to predomi- 
nate where the glandular diseases have been produced. It would 



138 ON INTERMITTENT FEVEKS. 

seem therefore from this fact, and from what I formerly stated 
respecting the production of glandular diseases in India as a sub- 
stitute for fevers, that such disorders may often be the cure or 
prevention of remittent and intermittent both, such as that cure 
is, instead of being the maintaining cause that has very common- 
ly been imagined. And that there are individuals who seem, 
from constitution, almost unsusceptible of the effects of Malaria ? 
is a fact already noticed in treating of remittent. 

Whatever else I might have said respecting this mode of the 
diseases in question, will be more conveniently deferred to the 
next chapter, since it is peculiarly entangled with the subject 
there treated; and I must now therefore proceed to describe the 
varieties of intermittent which differ from the well marked and 
more regular diseases of this nature; following the course which 
1 have pursued as to remittent. I might, with some affectation 
of refinement, divide these, throughout, into such terminable or 
acute cases as are of an imperfect or anomalous character, and 
into those which are limited to the chronic or persistent forms 
of intermittent; but so entangled are all these matters, that it 
could not be done without producing repetitions which would 
be but ill atoned for by such an attempt. It will be more con- 
venient and brief, in noticing these anomalous cases, to mark oc- 
casionally, in proceeding, under which of these two divisions 
they occur; while the far larger number will be found to belong 
to the chronic or habitual diseases. I also think it here super- 
fluous to recur to the subject of the types, since that also would 
be to prolong this account to little purpose: it being sufficient to 
remark generally, that the anomalous fevers, like the simpler 
chronic disease, may appear under any type. I may here also 
premise further, that as many of the remarks formerly made on 
the chronic remittent apply equally to the chronic forms of quo- 
tidian and double tertian, while, as I then also observed, differ- 
ent persons may choose to view this disease under these differ- 
ent terms, I may often be compelled into what may appear re- 
petition, though studying to avoid it wherever I can satisfacto- 
rily refer the reader to what was then said. And lastly, when 
I am compelled to notice the occurrence of local diseases in these 
cases, I must often refer to the last division of this essay, where 
I have been obliged to treat of them in one mass, for the rea- 
sons formerly assigned. Hereafter, should physicians become 
satisfied that the views which I have held out respecting these 
disorders are correct, it will become easy to remodel the whole 
history of the diseases of Malaria; but to have done this now, 
under evidence which may be deemed by many unsatisfactory 
or imperfect, would be to prejudge in some measure an impor- 
tant question, and to incur the charge of premature generaliza- 
tion and love of system. I must submit to the opposite charge 



ON INTERMITTENT FEVERS. 139 

of repetition and tediousness, that I may avoid this one; being 
placed between Charybdis and Scylla: and thus leave to some 
future observer the credit of doing what I might myself have 
easily done, had I thought it justifiable in the present stage of this 
question. ' 



CHAPTER VII. 



On the anomalous, obscure, and simulating Inter mittenis* 



In the very slender sketch which I gave of the well-marked 
and severe, or of the ordinary remittent, being as unable to avoid 
some notice of that form of fever, from its fundamental charac- 
ter and connexion with all these diseases, as I was, reversely, 
unwilling to repeat what has so often been written, I purposely 
avoided noticing those cases or epidemics where very marked 
local inflammations of different organs accompany it and modify 
its character; often indeed to such a degree in relation to the 
practice, as to render the mere fever of comparatively little mo- 
ment. I reserved that notice for this place; that I might, by 
means of that general fact, the better illustrate the anomalous, 
localized, or simulating intermittents, the knowledge and dis- 
crimination of which, and perhaps most of all in their slighter 
forms, appear to me so essential. 

Let me therefore now remark, that in remittent fever, there 
may be present, inflammations of the brain, of the lungs or the 
pleura, of the throat, (anginae of different characters,) of the 
bronchial membrane (catarrhs, of the stomach, the intestines, 
the liver, the spleen, the peritonaeum, perhaps of other internal 
organs or viscera, and also of the muscles and ligaments (rheu- 
matisms:) all of these varying in their intensities, in whole epi- 
demics as in individuals, and thus, at one extreme, producing 
cases, which, under peculiar characters also in the essential fe- 
ver, may simulate, or almost equal, cases of phrenitis, pleurisy, 
and so forth; calling for material variations in the practice, and 
not unfrequently becoming the grounds of most inconvenient 
disputes among physicians not sufficiently aware of the nature 
of what they had not witnessed; as also of recommendations as 



140 OBSCURE INTERMITTENTS. 

to the treatment, not less easily misapplied, and frequently 
highly pernicious in their results. 

Now if these local affections occur in remittents, or, as must 
equally happen, in marsh fevers of a continuous character, some- 
times even leading to error as to the fundamental nature and cause 
of the disease, or passing for pure inflammatory diseases when- 
ever the physician is unaware of the nature of the epidemic, or 
when its true character has not yet betrayed itself, so they oc- 
cur also in the severer intermittents, as might, without much ef- 
fort of thought, be expected. In these cases perhaps, the varie- 
ties are not only greater, but error is even more easy. The in- 
flammatory, or local affections, be they what they may, may be 
slender and truly supplementary; but they may also prevail so- 
far above the fever, as in remittent, that they may appear to be 
a distinct disease, or the superior one; while if, further, the lo- 
cal affection should be permanent or continuous, when the fever 
has its intermissions, and perhaps long ones, as in quartan, and 
while, still further, that fever may not be very conspicuous com- 
pared to the local symptoms, it is easy to see that erroneous 
views and erroneous practice may follow. 

That, as to intermittent no less than remittent, the occurrences, 
or varieties, which I have thus indicated do exist, ought prac- 
tically to be known to every one who has had any intimacy 
with those fevers; although, that they are but little known or 
suspected in England, is a fact which I believe I may with safe- 
ty assert. But those who are thus situated, may convince them- 
selves by consulting numerous, but almost solely foreign authors; 
while as one convenient reference at least for these cases, I may 
point out the nosology of Sauvages where such intermittents 
have even been distinguished as distinct varieties, as far at least 
as this laborious writer was enabled to produce authority. I am 
aware that he has been both censured and ridiculed for erecting 
these varieties, as if it were an unnecessary and trifling refine- 
ment: but, so far from joining in remarks which must have pro- 
ceeded from those who were unacquainted with this subject, or 
whom I must consider as uninformed or inattentive practitioners, 
I look upon these distinctions as of great practical value, by di- 
recting attention to varieties, an ignorance respecting which I 
shall shortly show to have been a fertile source of the greatest 
practical errors. 

Though I have thus referred only to the inflammatory local 
affections, as the most conspicuous in deducing this resemblance 
between the varieties of remittent and intermittent, the same 
analogy holds as to other variations or combinations, among 
which the nervous diseases, to use a popular term, form the 
great mass; or ? as there is a pleuritic remittent and a pleuritic 



OBSCURE INTERMITTENTS, 141 

intermittent, so apoplexy or palsy may be united in different 
modes to either mode of marsh fever. Such diseases, or such 
varieties of intermittent, will here be enumerated as far as they 
are known to myself, and also where, having never met with 
them, I can borrow from valid authorities; but I must now 
state, generally, the reasons why I have made of this subject 
so extensive and detailed a chapter, and how far what I have 
described, differs from what will be found in authors on inter- 
mittent fevers. 

I had long ago been led to seek for the chronic and obscure 
forms of intermittent, or remittent, (for a distinction is scarce- 
ly necessary) because I perceived that they were very general- 
ly overlooked, and because" I found that I could thus, not only 
explain, but cure disorders which had been considered mysteri- 
ous or inexplicable: a proceeding, of which the evidence ap- 
pears in many parts of this essay. In this pursuit I soon and 
necessarily perceived, that if many of these cases were surren- 
dered as inexplicable, in many others the prevalence of some 
peculiar and marked symptoms gave rise to error, as well in 
practice as in opinions, and often of a very serious nature: that 
symptom receiving the name of the original disease to which it 
most commonly appertained, or which, in some cases, it form- 
ed, and the adopted practice following, of course, the usual 
routine recommended for such diseases. If, in the course of 
these observations, I recollected in authors, single cases which 
seemed to confirm my own conclusions, I did not recollect that 
any general doctrine of this nature had been promulgated, and 
assuredly it had not been taught in the medical schools, while 
the more I watched the general practice of others, the more I 
was convinced that it was either a neglected or an unknown 
subject. Considering it therefore as of great importance, and 
the neglect as not less so, I resolved to generalize the facts as 
far as I could, and to allot for it a distinct and formal chapter; 
dwelling on it also with a detail which I should certainly not 
have adopted in any case of known disorders, because thus 
hoping to making the greater impression. 

In how far I was justified in thinking that medical writers in 
general, and the authors on intermittent especially, had not 
formed any definite opinions on these anomalous and simulating 
intermittents, will appear hereafter, when I shall have occasion 
to quote their detached cases; when I shall then also show, that 
my own observations could not have been biassed by what I 
had not then read. But I must remark here, that while I had 
at one time supposed that this was not a new question, howe- 
ver much I might have thought so from observing how little it 
seemed to be known by our present practitioners, and how lit- 
tle, even the most recent authors on such a disease as palsy fox 



142 OBSCURE INTERMITTENT3, 

example, seemed to be aware of it, forming this passing opi- 
nion from an inspection of nosological tables and indexes, a fur- 
ther examination proved that I was here in error, and that my 
original conclusion, namely, that it was a neglected subjeet, 
was the true one. 

That examination taught me, that with few exceptions, which 
I shall notice in their proper places, the anomalies or peculiar 
diseases appearing under marsh fever, which authors had de- 
scribed, related to acute and violent diseases, intermitting as 
well as remitting; and that, as a sort of general neglect, as if by 
a kind of universal consent, had reigned respecting pure chro- 
nic intermittent, so very particularly, it was scarcely any where 
indicated, that disorders apparently original, might be united to 
chronic as to acute marsh fever, and still less that these might 
be so constituted as to deceive the physician, from the obscure, 
irregular, or nearly insensible state of the proper fever. In 
some authors I did indeed find indications and cases of this na- 
ture, as I shall hereafter point out; marking principally Strack, 
as the chief collector of facts, but even then, not being able to 
perceive that he had formed any general views on the subject, 
and the more convinced of this from finding that later systema- 
tic writers, such as Philip, had not, in their otherwise praise- 
worthy books, appeared to derive from him, while largely re- 
ferring to his authority, the conclusions which I had been led 
to adopt from my own observations. 

Thus much I thought it necessary to say in defence of the 
space which I have occupied in this chapter, and in defence of 
my thus making a separate chapter of what has been treated not 
merely with neglect, but, as I have elsewhere said, with ridi- 
cule: and I have only to add, therefore, that while I consider 
the chronic, anomalous, and simulating cases as even more de- 
serving of discussion than the acute ones, inasmuch as they are 
less suspected and more frequent causes of error, so whenever, 
with little exception, I refer to a title in Sauvages, it must be 
remembered that his examples do not exactly tally, inasmuch as 
they are very generally instances of the acute, and not of the 
chronic diseases. 

Lastly, thus strongly to distinguish between acute and chro- 
nic forms of one disease, and thus to dwell on the latter rather 
than the former, may in reality not be very consonant to the 
usages of medicine, or even of science; but the justification must 
be sought in the causes I have already stated, while it must be 
remembered that if it was fruitless to dwell on what was alrea- 
dy well known, the object of this essay is Utility. If I suc- 
ceed in attaining this end, I shall little lament any censure that 
may follow as to other matters. 

I would willingly have adopted a more formal order for what 



OBSCURE INTERMITTENTS. 143 

is about to follow, as I would willingly have treated of many of 
the varieties which I have noticed, in more detail. But I have 
imagined that arrangement which best illustrated the matters 
described, to be better than one which should have no other me- 
rit but its regularity; and as to the other point, it has been a 
leading object to keep these discussions within as small a compass 
as possible, lest an inconvenient bulk should become the conse- 
quence. I shall now commence with the affections in which 
the nervous system is chiefly or ostensibly implicated. 

I formerly noticed the apoplectic state which sometimes com- 
menced the attack of intermittent as well as of remittent; but it 
is necessary to recur to it here, on account of its great impor- 
tance as connected with the practice in these disorders, and be- 
cause of other analogous symptoms sometimes occurring. This 
state is not limited, either to the first attack or to the acuter forms 
of these fevers, although in Italy that appears to be the most 
common mode of its occurrence; as I have seen, in this country, 
a perfect apoplexy, to the eye, in all its characters, sufficient to 
deceive both the attending practitioner and the friends, lasting 
for eight hours, and occurring in a chronic tertian of many years 
standing, as a substitute for the cold fit. 

The danger of error as to the nature of such an attack is, in 
practice, very great, as I shall hereafter more fully show; since 
the effect of blood-letting, so commonly resorted to by practi- 
tioners under such symptons, be the cause what it may, is often 
to induce palsy, sometimes death, and, in any case, to produce 
additional bad symptoms, often of a very serious nature. In 
many instances, I have seen local and limited paralytic affections 
produced by this mistaken practice, and in more than one, a per- 
fect and incurable hemiplegia; while I have reason to think that 
this has happened very often in Italy, in the hands, however, 
chiefly of English practitioners unacquainted with this anoma- 
lous variety; though I also know that it has been the result of 
Italian practice, notwithstanding the much juster views generally- 
entertained in that country respecting these " febbri larvati.* ? 
It will be for English practitioners in our own country, and chief- 
ly for those who live in the agueish districts, to inquire whether 
they have not committed similar errors; while there is reason to 
suspect that they are not very uncommon, or rather, extremely 
frequent. 

A modified condition of this nature, is the lethargic or coma- 
tose state, which occurs in the chronic intermittents as well as 
in the remittent of that character, and which also sometimes 
ushers in the first attack of an intermittent, in the same maimer 
as the more perfect apoplexy does. It is incumbent on the 
practitioner to investigate this symptom or condition where H 
occurs, much more accurately than it is the custom to do: while 



144 OBSCURE INTERMITTENT?, 

it is abundantly easy to discover whether it belongs to this disease 
or not. To view it as an independent disorder, and as arising, 
according to the popular and fashionable error, from what is call- 
ed a flow of blood to the head, is a most unpardonable mistake, 
from its leading similarly to injurious practice; to blood-letting 
and to cupping: the consequences of which also are, sometimes, 
paralytic affections, at others, slight epileptic ones, or even more 
decided fits of that disease; in others again, a modified fatuity, 
or a diminution of the intellectual powers, or a condition little 
short of absolute idiotism: and, even, in the least evil event, a 
long train of debility and nervous symptoms, with the further 
frequent consequence, as in the former case, of rendering chro- 
nic a disease which would otherwise have terminated by itself, 
or of protracting much longer and more severely, a disorder al- 
ready chronic. It is one of the cases, and one of the modes of 
practice, yet but one out of many, which so often causes medi- 
cal interference to aggravate the diseases of this nature. I shall 
only further remark, that this error is most generally commit- 
ted, as I have seen in numerous instances, and as perhaps might 
have been anticipated, when the patient is corpulent, or of a 
certain form, or advanced in life, or when suspected of indul- 
gence in eating and drinking: when it will be fortunate if he es- 
capes blood-letting or cupping, to be simply deprived of the use 
of wine, or restricted in diet; though even practice of this mode- 
rate nature is not always without its bad effects. 

As connected with these I may proceed to the palsies or para- 
lytic affections which sometimes occur in this disorder; forming 
an anomaly, if 1 may so call it; and sometimes, as in other ana- 
logous cases, when so marked in comparison to the febrile con- 
dition as to appear the sole or real, or the chief disease, produ- 
cing a simulating disorder, it may be, even to an attentive phy- 
sician, unless aware of this particular fact; while, as far as I can 
discover from all the reading on this subject in. which I have 
engaged, or from observation of the opinions and practice of 
England, this knowledge is rare, or perhaps scarcely exists. At 
least I have not myself found any practitioners who seem to know 
that palsy is the frequent produce of Malaria, or the substitute for 
intermittent {ever, or a symptom in that disorder; while it is 
plain that if this be a common case, at least, among the well 
educated, if not a general one, there must occur, in practice, to 
persons of a different class, many cases of this nature, where the 
paralytic disease is even attendant on a very distinguishable or 
marked fever, and where nevertheless that would be overlooked, 
from the attention of such practitioners being absorbed by the 
ostensible symptom. I need only add, as a prefatory remark 
to this particular subject, that paralytic affections of this nature. 
or appertaining to this cause and connexion, occur also in the lo- 



OBSCURE INTERMITTENTS. 145 

ca] intermittent disorders ranked under Neuralgia, so that they 
must inevitably come under review again: but I could not, in 
any view, avoid treating of them here, and very particularly on 
account of their connexion with the apoplectic affections just 
discussed. 

Apparently as a substitute for, or modification of, apoplexy 
or coma, however obscure the exact cause may be in either case, 
the first attack of an intermittent is sometimes a numbness, or 
a more perfect paralysis, varying in its extent as well as its se- 
verity, so as to affect only a few muscles, in different parts, or 
else to produce an absolute hemiplegia; which, however, may 
also be slight as well as complete, or may consist in a numbness 
or loss of feeling to that extent, without depriving the patient 
of his command over the muscles. Should the truth of such a 
cause for palsy be denied on the ground that we cannot explain 
its action, it must be recollected that it is no more a mystery 
than the production of apoplexy in the same cases; while the 
possibility is confirmed by the numerous instances of the same 
nature which occur, limited to single, and sometimes very small 
nerves, and either original, or succeeding to painful conditions 
of those. Every thing indeed tends to show, that if the diseases 
produced by Malaria are not, purely, and all, mere affections of 
the nervous system, the principal action of this poison is on that 
system, and the greater proportion of the disorders which are 
caused by it, disorders of the nerves. Whether the paraplegia 
so often occurring from exposure to cold, and especially among 
soldiers in bivouacs, is sometimes, or ever, a disorder of this na- 
ture, is a question that I cannot answer from such evidence as I 
have been able to procure, however this may be suspected in 
some cases. 

If these paralytic affections sometimes usher in a new inter- 
mittent disease, being, like the coma, a sort of substitute for the 
cold fit, so have I seen them occur in the chronic state, and, in 
both, under circumstances that could admit of no dispute as to 
their real nature. A single fact, out of many similar, will serve 
to explain the grounds of this judgment. This is, that in a situ- 
ation exposed to Malaria, and never free from its diseases, where 
in fact scarcely any one ever escaped it, while the other mem- 
bers of a large family had the intermittent under different, but 
ordinary, forms, two were attacked with paralytic affections, 
suddenly; the one in the leg and thigh, the other in the arm. 
Being the younger members of the family, and though it was 
the first time that any case of this nature had come under my 
notice, I viewed these palsies as modes of the apoplexy of inter- 
mittent; and the judgment was confirmed by the almost sponta- 
neous disappearance of the disease in both, and the immediate 
establishment of the regular quotidian. In the chronic cases, 

19 



146 OBSCURE INTERMITTENTS. 

there ought never to be any doubt, because the preceding inter- 
mittent explains the cause; though the most serious errors may 
be frequently found in practice, even in cases of this more obvi- 
ous nature. 

The practical error in the case of such paralytic affections, is 
the same as that in the former two conditions; the imagining a 
" flow of blood to the head," and a palsy to be treated by bleed- 
ing and evacuants; and the result very often is, perhaps in se- 
vere attacks always, to confirm as a perpetual palsy, that which 
would have passed away of itself, had there been no interference, 
or which would have been removed by the common remedies 
for intermittent. If there are many other cases of palsy occur- 
ring in practice, which might otherwise have been temporary, 
whether arising from the effects of cold or not, and which have 
been rendered incurable by this pernicious and common treat- 
ment, I have little doubt that innumerable ones will be found, 
by those who have the means of making the inquiry, where 
this result has been the consequence of such evacuations applied 
in the palsy of the intermittent. 

Of such cases I might have stated a great number from my 
own observation; respecting which, while I entertained no doubt, 
even on the first inspection, the confirmation was rendered com- 
plete by the previous history of the patient, by his diseases, his 
residence, and his treatment. But to relate those, is to subject 
myself to the suspicion of having viewed them under an hypo- 
thesis of my own; for which reason I will here describe one or 
two not under my own care, because, while I suspect the nature 
of them to be that which I have stated, I shall leave the decision 
to others; taking from the reports of the physicians engaged, 
what I had not the means of examining personally, but taking 
only the naked facts, as the medical attendants had formed no 
opinions respecting the cause. In the consequences, they coin- 
cide exactly with what I have seen where I could pronounce on 
that cause. As to the utility of such cases, it is that they will 
serve the purpose of directing the recollections of practitioners to 
what they may have seen under similar errors; while a very 
wide range of observation, prolonged during thirty years, con- 
vinces me that this species of error is not only common, but al- 
most universal. 

In the first case, two sisters, in one family, about the age of 
thirty, were strongly marked with that complexion and physi- 
ognomy so well known as attendant on diseased spleen, and were 
subject to those strange symptoms, of various kinds, which oc- 
cur in the chronic intermittents, already described for the most 
part. It had also happened that they had passed a large portion 
of their lives in one of the most pernicious districts in England; 
but whether they had suffered from acute intermittent, I was 



OBSCURE INTERMITTENS. 147 

not informed. The occurrence of what are, very indefinitely, 
called spasms, led to bleeding in both cases; and this, producing 
more nervous symptoms, was followed by more bleeding and 
more cupping. The result, in one of these patients, was hemi- 
plegia, and in the other, paraplegia; and further bleeding being 
also resorted to for these disorders, both of them died. 

For the other case, I must borrow from a medical friend; glad 
of facts from those who have not the bias of which I may be 
suspected. It was that of an officer, in whom it could however 
only be conjectured that intermittent was the original disease; 
but it will serve at least to illustrate the effects of blood-letting 
in such cases, by, I believe I may say, whatever cause produced. 
An inexplicable palsy of one limb was here the first occurrence, 
and in a man of a constitution and time of life where the usual 
vulgar cause could not be suspected. Blood-letting was followed 
by palsy of the other leg; and on repeating it successively, both 
arms, one after the other, became similarly affected, so that the 
patient at length became and remained almost an immovable 
carcass. It is not known to my reporter how this case termi- 
nated: and if it is not absolutely proved to be an instance of this 
nature, it coincides so exactly with those which I have seen 
where the same practice produced similar effects, that I enter- 
tain little doubt of its having been the palsy of intermittent. 

To confirm at least the possibility of so universal a palsy, and 
arising from Malaria, I may quote a case related by Keratry, 
occurring in that poisonous district in France, He et Vilaine; 
where, while the internal functions were carried on, the patient 
was for many years so utterly paralytic, that nothing but one 
side of the face was capable of voluntary motion; though, as the 
treatment is not related, no suspicion appearing to have existed 
in France more than elsewhere, of such effects being produced 
by bleeding, it can only be conjectured that this practice had at 
least aggravated that effect of the previous disease, or that a par- 
tial palsy had, as in the preceding case, been rendered universal 
by, probably, repeated blood-letting. That a universal palsy 
is also possible, is confirmed by Etmuller; while here at least 
there is no difficulty in tracing the disease to an intermittent. 
It succeeded to a tertian which had lasted during a year, and was 
accompanied by nocturnal sweatings, pains in the hands and feet, 
and a livid countenance: while, with an ignorance which appears 
somewhat surprising, it was attributed to scurvy, and called 
scorbutica; apparently from the colour of the face: there being 
little doubt, from this, of the presence of a diseased spleen, 
while it is by no means unlikely that the palsy had been the 
consequence of an evacuant practice. 

The following case is of a similar nature, inasmuch as it serves 
to prove the pernicious effects of this practice; while it illustrates 



148 OBSCURE INTERMITTENTS. 

that, perhaps even more strongly, in consequence of the gradual 
cure, aided probably by change of air, which followed its sus- 
pension. It is also an explicit one, though but one out of many 5 
since it elucidates the connexion, equally, between apoplexy and 
palsy, and intermittent: while valuable in another sense, as show- 
ing how easily the palsy succeeding to the apoplexy in this disor- 
der, whether from mal-practice or otherwise, may be mistaken 
for that disease depending on original apoplexy. In this exam- 
ple, an officer, a young man, who had suffered from the remittent 
fever in Spain, was suddenly seized on an English parade with 
a fit, or what is commonly called such, which was considered as 
apoplexy; being in reality a return of his intermittent. Being 
placed under the usual discipline, he was rendered partially para- 
lytic, and at length, under two years of the general routine, be- 
came the mere shadow of a man, while previously most robust; 
losing also, with his strength, the better part of his intellect 
Determined at length to join his regiment in the West Indies, 
he embarked in a transport, where, from there being no surgeon, 
all medical practices were suspended; from which moment he 
began to recover, and concluding just what I have here conclu- 
ded, was in a few months restored to perfect health. 

With respect to this consequence of intermittent, or of marsh 
fever generally, and very particularly of the effects of the evacu- 
ant system in producing it where it would not have occurred, or 
of aggravating it where it is existing, I have reason to be sur- 
prised that it appears to have made little impression in Italy and 
France, compared to what might have been expected; that judg- 
ment being formed from at least different and numerous works 
which I have read on this subject, if I have not read every thing. 
That Keratry was unaware of it, and that his reporter, Monfal- 
con, offers no commentary of the same nature, appears to me a 
sufficient proof of the truth of this suspicion; namely, that al- 
though the general fact is known and admitted, due value has 
not been placed on it, and very particularly, as it does not seem 
to have been observed that such as I have noticed is the result 
of blood-letting. Were not my own experience ample and satis- 
factory on this point, this would have rendered me doubtful of 
my own conclusions-, but that has been far too wide and precise 
to permit me to surrender my own judgment, even to authority 
and experience such as I have named. And if I have received, 
from Italy, English patients, rendered paralytic under Italian 
practice, in these very circumstances, and by this treatment, and 
when the whole his'.ory was most precise and clear, I am com- 
pelled to believe, that even in that country as well as in France, 
the palsy of marsh fever is not understood as it deserves and re- 
quires, important as it is; while I am sure that they who will 






OBSCURE INTERMITTENTS. 149 

seek for such cases, will soon find ample confirmation of all that 
I have here asserted. 

Of partial palsies in the face, and of more general ones in the 
legs and in the arms, traced by the patients to cold, and, under 
my own views, appertaining to intermittent, I have known ma- 
ny instances rendered complete or incurable by blood-letting, 
when, from my own experience in similar ones, I have reason 
to believe that they would have passed away had the physician 
not interfered. 

Of these, I need not relate the cases themselves, since the 
fact must be familiar to almost every practitioner: while I am 
bound to remark that although often attributed by the patients 
to cold, it is the usage, that of habit and carelessness, to imagine 
some affection of the head, and to treat them accordingly by 
evacuations; thus generally aggravating or extending them, or 
rendering them incurable. Even when, in more careful hands, 
or from whatever cause, this pernicious practice is not followed, 
they are viewed as merely local disorders, and treated in a man- 
ner which is nugatory; in consequence of which they often also 
become inveterate, and at length, possibly, incurable. So im- 
portant do I consider this view of paralytic diseases, and so en- 
tirely have I found it neglected, even by modern and recent 
writers on palsy, as well as by writers on intermittent, that 1 al- 
most wish I dared take room for such cases as might serve to 
make a deeper impression than what I ought perhaps to expect 
from this general statement, strongly as I wish to urge it by thus 
•dwelling on it. 

When I name this neglect, I ought to point it out distinctly, 
that a term thus often carelessly used may not be supposed care- 
lessly applied. The fact itself is, that if it has not been my 
good fortune to see every treatise on pals}^, I have read a great 
number, and the most recent; while I may conclude that what 
the latest compilation has not noticed, is not very likely to exist. 
And if, in these books, I have found no account of such a cause 
of palsy, in some, even in the most recent of all, (which to 
avoid appearing to censure the author I will not name,) there is 
not even the slightest allusion to it; as if the physician, wri ting- 
on this express subject, had never even heard of such a cause for 
the disease which was his especial study. And when I recur 
to a long series of observation, much more on the practice of 
others, of course, than in my own, I find such a mass of cases 
where it was to be often proved, very often suspected, that the 
paralytic affections arose from this very cause, that I am com- 
pelled to conclude that, in the first place, the cause in question 
is a very general cause of palsy, and, secondly, that the error of 
practice arising out of a wrong theory and the common one, is 
the source of the far greater number of incurable palsies daily 



150 OBSCURE INTERMITTENT?*. 

met with in society; the increase of which also has been noto» 
riously great for some time past, while it bids fair to proceed in 
augmentation, as the diseases of Malaria, from whatever cause 
arising, are themselves increasing, and as the improper practice 
to which I have alluded becomes also daily more prevalent. 

But besides the more palpable and sudden paralytic affections 
attending intermittent, and under whatever modification or in 
whatever stage of the disease they occur, there are others of a 
more gradual nature which it is necessary to point out, not mere- 
ly from their bearings on the practice in this disease, but from 
the light which they throw on the nature of intermittent, and 
very particularly on the other local affections belonging to it. 
If the variety in the effects or the appearances may be considera- 
ble, regulated as these must be by the nature of the nerves affected, 
and by the extent of the affection, it will be sufficient to describe 
one of these cases, and that account will perhaps also form the 
most convenient description. 

This was an instance of a relapsing or chronic quotidian, in 
which there had, at no previous time, been observed any affec- 
tions of this nature. During the relapse, in question, which last- 
ed the more general time of six weeks or two months, there 
came gradually on, a feeling of weakness in one leg, and more 
particularly in the foot, which increased so much during the 
disorder, that the patient could with difficulty make a step on 
that foot. And although there was no pain, or Neuralgia, it 
was easy to trace with the finger the course of the fibular nerve 
from the middle of the leg into the foot; as the slightest passage 
of the finger over it was attended by the well known tingling 
sensation produced by a pressed nerve; while a stronger pres- 
sure where it is nearest the surface, gave the equally well- 
known shock produced by striking the elbow, in another super- 
ficial nerve. It was obvious that the muscles chiefly affected in 
this case, were those to which this nerve principally belonged, 
and therefore that it was in a diseased state; that derangement 
appearing to consist in a diminution of its energy or power^ 
added to an increased or morbid sensibility. The analogy of 
this to the proper Neuralgia is evident; and it must be con- 
sidered, in fact, as a modified degree of this disorder, offering 
one of the proofs, out of so many, respecting the real nature of 
this disease, or its connexion with the intermittent and Malaria. 

In this case, the relapse now described was succeeded by one 
much more severe, and successively by a third, more serious 
still. In these, the affection of the nerve of the leg, which had 
become little noticed during the interval, returned with increased 
severity; while, in the first, there came on a similar affection of 
the ulnar nerve of the right arm, and in the second, a similar 
one of the left; the others remaining. In this, most complete 



OBSCURE INTERMITTENTS. 151 

attack, the courses of the nerves in both arms could equally be 
traced by the finger in the same manner; while, further, the pa- 
tient was unable to extend the arms without immediately feel- 
ing the tingling, as of a compressed nerve, along the whole course, 
from the arm-pit to the fingers; that sensation being increased 
by increasing the extension. And in this case also, it was evi- 
dent that the muscles chiefly supplied from those nerves were 
the ones affected; being feeble, or occasionally benumbed, as in 
the leg. Whatever be the exact affection of the nerve in this 
case, it it plain that it must be of a local, and, if I may use such 
a term, of an anatomical nature; or that it was one which might 
possibly have been ascertained by dissection and inspection, had 
that been possible, and were we sufficiently acquainted with the 
intimate or ultimate structure of a nerve. 

I need only further add respecting this case, that while the 
nerves of the arms recovered, yet very slowly, after the cessa- 
tion of the fever, that of the leg remained diseased for many 
years after, and perhaps continues so still; extremely sensible on 
casual pressure, even as far as the toe, so as to render great pre- 
caution necessary in walking, while the debility of that leg re- 
mained equally marked. If we see here the resemblance of this 
condition to that which succeeds to decided Neuralgia, so is its 
resemblance to the effect of sciatica on that particular nerve 
equally obvious; while I propose hereafter to consider sciatica, 
in all cases, as a pure and perfect Neuralgia. 

Considering apoplexy to be one of the general or more exten- 
sively constitutional anomalies of the intermittent, or of marsh 
fever in general, as it is also the best known, I would willingly 
have separated it from the less general, or more local disorders 
of an analogous nature, or from the paralytic affections depending 
on the same cause, and deferred those till hereafter, so as to have 
treated of all the confined or partial disorders in one general 
view. But their natural connexion rendered that inconvenient; 
nor, where palsy is sometimes a general disease, and sometimes 
a purely local one, is it possible to adopt any arrangement which 
shall be unexceptionable. To have introduced it here was in- 
dispensable, even though it must be noticed again hereafter: and 
while I am bound to quote such authorities as I can find, in sup- 
port of these views, I may therefore introduce them here, and 
perhaps more usefully than at a future period of this essay. 

As I have more than once remarked in this essay, while the 
observations on which it has, throughout, been founded, were 
purely drawn from my own experience, without reference to 
authors, without even being aware that what was not taught in 
modern systematic writers and medical schools was at all known, 
and as the very essay itself was written before any such refer- 
ences were made, I shall here, as on other occasions, supply the 



152 OBSCURE INTERMITTENTS, 

parallel cases and authorities which I have since found, without 
disturbing what I had written; because, thus, as it appears to me 
at least, will the reader feel more confidence in the facts, as being 
the uninfluenced observations of independent and remote ob- 
servers. 

On many of these cases, as on their authors, I must also re- 
mark, what I think essential, but for purposes of utility, not for 
the sake of criticism, that it has rarely been seen that the para- 
lytic affections were really an inherent portion or variation of 
the disease, while, too frequently, they have been looked on as 
mysterious cases, more generally as incidental combinations. 
The former has been particularly the case where these affections 
have possessed any remarkable peculiarities, and most of all 
where they have been united to other nervous symptoms. To 
place the few cases which I have thus selected out of the num- 
ber, in a condensed approximate order, and with such remarks 
as I may venture to make on them, will, therefore, I trust, be of 
the greatest use, by opening the eyes of practitioners to what has 
been strangely neglected or misunderstood. And if it has not 
been seen, and by physicians of such high reputation as I must 
here quote, that palsy was so often but a mode of intermittent, 
there is the more excuse for the large mass which can never do 
more than follow; while I am inclined to attribute this serious 
error, in a great measure, to the errors that have been as univer- 
sal respecting Neuralgia, or to ignorance of the real nature of 
this disease: while the. occurrence of palsy in those local inter- 
mittent affections, not only illustrates the general fact, but draws 
still closer the analogy between those diseases and ordinary in- 
termittents. 

As a marked instance of a paralytic affection of a peculiar 
character, though permanent, Sauvages quotes a case from Fa- 
bricius, where, in an epidemic dysentery, which, I need not re- 
mark, is but a mode of marsh fever, there was a palsy in one 
arm and the alternate foot, produced, says he, by the improper 
use of astringents and opiates. He calls it obscure; thus addition- 
ally proving that neither he nor his author was aware of the con- 
nexion which I have here been pointing out. The only other 
remark I may make on it is, that it could scarcely have arisen 
from any conceivable disorder of the brain, as it is too much the 
custom to suppose; since two parts so discordant in position, 
could not thus have been easily deranged through the brain; 
while it offers a tolerably convincing specimen of the origin of 
this disease in derangement of the nerves themselves. 

But when the same nosologist quotes from Chaptal, a case of 
Hemiplegia under the very term tertiana hemiplegica, it might 
be supposed that the criticism which I have just made was 
unfair, particularly as the disorder was cured by purging and 



OBSCURE INTERMITTENTS. 153 

bark. Yet we find nothing among those details and remarks, of 
which he is assuredly not sparing, to make us think that he was 
really clear on this subject; and as to this particular case, in spite 
of his term, it would appear that the bark was given to cure the 
tertian, and that the combination was considered as accidental 
rather than dependent. 

A more marked case, quoted by this assuredly learned and 
industrious physician, ought, it might be supposed, to have com- 
pletely opened his eyes on this subject; and with this and other 
instances which he has quoted, together with the adoption of the 
term above-mentioned, and not only of that, but of other terms to 
which I have here often referred, I had expected, on consulting 
him, to find not only this part of my subject, but the whole 
question of simulating intermittents, not merely illustrated, but 
established and anticipated: an expectation in which I was dis- 
appointed. In this case, the paralytic affection came on every 
day, and disappeared with the accession of the proper quotidian. 

Palsy in the form of paraplegia, of a periodical and quotidian 
intermitting character, is also described by Torti, from Chaptal. 
Where the same writer, from the same authority, quotes a simi- 
larly periodical hemiplegia absolutely perfect, while it was quo- 
tidian and intermitting, lasting also for ten hours, he remarks, 
that it was always increased by purging as well as by blood- 
letting, and that on changing the practice, it was cured by bark 
in nine days. This particular case is of value, as a warning to 
practitioners; and, from the nature of the attending and preceding 
symptoms, perhaps, of somewhat more value than common. No 
intermittent fever seems to have been at first suspected, by the 
description, which notes only a vertigo, attended by a full and 
quick pulse and a burning heat in the head. How easily this 
may, in any other such case, be attributed to disease in the brain, 
is most apparent; as in truth I have seen more than once in the 
practice of others, while unable to enforce my own views; while 
it is abundantly plain, that had these symptoms been duly noted 
and described in the related cases, they were but those of inter- 
mittent fever; possibly, indeed, in this instance, and in other 
cases besides this one, partial, as that disorder so often is in its 
paroxysms. 

A case from Morgagni is even more remarkable than some of 
the foregoing: because, in this, one side was permanently para- 
lytic, while the other was attacked every evening with a palsy, 
which disappeared in the morning; the patient, after seven or 
eight such fits, dying of peripneumony. Various irregular cases 
of the same nature, where the palsy was attended by convulsions, 
are noted by the same author; while as far as I can perceive, 
neither he, more than Sauvages, appears to have been aware of 
the true connexion between the palsvand the intermittent. And 

20 



154 OBSCURE INTERMITTENTS. 

when I consult the writers on palsy specifically, even those as 
recent as Cooke and Swan, I do not find, although such cases 
are quoted and referred to, that their nature had been appre-. 
hended, or that any suspicion seems to have been entertained 
that Malaria w r as a cause of palsy, or that there was a mode of 
this disease especially dependent on intermittent. 

It is scarcely less remarkable, that although in the medical 
reports of the army, it is noticed that a predisposition to palsy 
and apoplexy was frequently produced by " fever, visceral dis- 
ease, and dysentery," no such remarks are deduced from this, 
even by those writers on palsy who quote it, as, I trust the 
reader will now perceive, it ought to have produced. Whether 
Strack, who has collected so much respecting anomalous inter- 
mittents, had been fully aware of this connexion, it is not possible 
to know; but if we judge from his book, where he relates but 
one case, and that of apoplexy and hemiplegia united, in a girl 
of eighteen, and cured by bark, we should conclude that he had 
not formed any definite ideas respecting it, nor generally indeed 
on the entire subject, since he enters into no general discussions 
on the question: rather appearing to have been guided in his 
practice by a strong affection towards this remedy, as a means of 
cure in numerous diseases never considered by him or any one 
else as appertaining to intermittent. Hence, his work, valuable 
as it is, is only so as a register of useful cases; since he has left 
to others to generalize and explain what he apparently did not 
view in the light which it required. 

And while I feel a great debt to a writer from whom I have 
derived many valuable facts, perhaps even the more valuable 
from their precision and simplicity, and from the total want of 
any general theory under whfch they might have been observed 
and registered, I must be allowed to say, that they appear to be, 
throughout, in a philosophical sense, empirical facts, and under 
an empirical practice: while if even perhaps more valuable for 
my purpose, from their independence and freedom from bias, 
from that bias which a philosophical view might have given 
them, I must consider that we have thus lost a great deal which 
his experience and assiduity, united to his apparent accuracy, 
might have collected, and would have collected, under such ge- 
neral views as the present; of which he seems to have entertained 
no idea, or of which at least he has assuredly given no indication. 

If I have remarked that Morgagni describes cases of this na- 
ture attended by convulsions, as there are also cases, noticed 
here, in another place, where mere convulsions or perfect epi- 
lepsy, alone, formed the variations of the intermittents, others 
may conjecture whether an obscure passage in Hippocrates, 
where he says that convulsions sometimes supersede and remove 
a fever, may not be explained in this matter, since, otherwise, 



OBSCURE IKTERMITTENTS. 155 

the explanation is not very obvious. One case, mentioned by 
M. Baumes, is valuable on account of its definite character un- 
der this combination, and because it may serve to illustrate more 
obscure ones: the paroxysm, which, in my view, should have 
been that of an intermittent, consisting of convulsions, attended 
by a palsy of the tongue. 

Of such obscure cases, I shall point out one especially, which 
has been represented as of a very mysterious nature: and while, 
to myself, it appears that it can be explained in this manner, 
and only in this manner, or that it was a chronic and a simula- 
ting intermittent, I must leave that to the judgment of others, 
after they have read this essay, while apologizing to those whose 
difficulties I thus endeavour to explain. This is the self-related 
case of Vieusseux in the Med. Chir. Trans, reported by Dr. Mar- 
cet, which I need not transcribe, as it is so easy of access, while 
of great length: and if, on reading, it may appear too intricate 
for the solution which I have proposed, it must be recollected 
that when a patient, and he a physician, describes his own case, 
and that a nervous one, minutely, the details here found are not 
a very unnatural result. But I shall allow practical physicians 
to reflect on this subject, and to consider how far they may find 
solved in the same way, any similar difficulties or mysteries that 
may have occurred in their own practice. 

To return to the principal simulation of intermittent connected 
with this one. I need not repeat that the case of apoplectic in- 
termittent is much better known, and is indeed really under- 
stood, at least in Italy; a fact which renders it the more sur- 
prising, that obscurity or misapprehension should have so gene- 
rally existed respecting the paralytic variety. On this, I have 
nothing therefore left to do but to quote a few authors for the 
purpose of reference or illustration. That single cases are com- 
mon, I have already said: and he who desires to read authority 
on this subject, may consult Ramazzini, who describes this oc- 
currence at all periods of the disease as well as at the commence- 
ment It was also known to Morton, who, perfectly aware, as 
we must suppose, of its nature, recommends bark. It is a more 
remarkable fact, and especially worth noticing, that in certain 
seasons, not less than in certain situations, as I formerly re- 
marked, or in certain epidemics, this variety has prevailed: 
while it will form sufficient examples of this, to refer to Thion 
de la Chaume for two seasons of such a tertian occurring at 
Ajaccio in 1773 and 177S; and for a similar event, in Bresse, 
the most pestiferous part of the Lyonnais, to Delorme. How 
far the epidemic prevalence of such a variety may prove that 
Malaria is a variable poison, or that its different effects depend 
more on quality than quantity, is, after what I have formerly 



156 OBSCURE INTERMITTENS. 

said on this subject, a question which I do not well know how- 
to contemplate. 

In terminating this part of the subject, I must not omit to 
mention an instance of the shaking palsy, as it is called, follow- 
ing an intermittent, described by a Scottish physician whose 
name has escaped out of the list of my quotations. A particu- 
lar value attached to this case is, that arsenic has been frequently 
accused of producing an effect which we here see is but a result 
of the disease itself. 

Having dismissed this very main portion of the present sub- 
ject, I cannot well elucidate what immediately follows, without 
returning to the chronic intermittent in its simple form, and to 
certain facts which were passed slightly over, that I might no- 
tice them here, or were purposely reserved for the sake of the 
present elucidation. 

Whatever the type may be, the paroxysm itself is subject to 
variations from the more perfect form of that as already de- 
scribed, analogous to those differences which are found between 
the chronic and the simple remittent. Thus it may happen that 
the duration of the cold fit may be very brief, and also very lit- 
tle marked in any manner. The sensation of cold may be so 
partial as to occupy but a limb, or a single spot, and even but 
for a few minutes; while, if more universal, it may be equally 
short, and also slight. It will further happen that there is not 
even the feeling of coldness; and the substitute for it may be 
the comatose state, in a slight degree, or mental affection alone, 
consisting in melancholy or irritability, or displaying itself in 
various practical modes unnecessary to detail; or it may be, ge- 
neral restlessness, or mere inability of mind, or the sense of fa- 
tigue, or debility, or, even more simply, a mere insensibility to 
pleasurable impressions; symptoms occurring in the very slight- 
est cases only, if they occur alone. Or, in somewhat severer 
degrees, it may consist in thirst, in loss of appetite during a cer- 
tain period, or in headach; or it may be marked by nothing but 
an increased secretion of urine, or lastly, it may be scarcely sen- 
sible to the patient himself, used to constant ill health, and be 
only recognised in that peculiar physiognomy which I have al- 
ready described. Thus also, more or fewer of these symptoms 
may be combined, or they may vary in degree, separately or 
united, so as to produce an infinite variety of appearances to 
the practitioner; while it is under these anomalies or imperfec- 
tions, that this disorder is often the subject of mistakes similar 
to those which occur respecting the chronic remittent. Hence, 
as in remittent, imaginary atrophies, imaginary consumptions, 
dyspepsia, hypochondriasm, nervous affections, headachs, and 
much more, leading to wrong practice, and not seldom to the in- 
creased suffering of the patient or the entire ruin of his health. 



OBSCURE INTERMITTEKTS. 157 

In the chronic intermittent also, there are the same uncer- 
tainties respecting the hot fit, whether as to length or intensity; 
as is not less true of the sweating stage: and in the milder cases, 
it is frequently difficult to mark any of the portions of the parox- 
ysm; while, further, any one, or even two out of the three, may 
be absent altogether, or else so slight as to escape a careless ob- 
server. In extreme cases of this nature, the whole paroxysm 
is an indefinable period of various inconvenience, with scarcely 
any point where either of the stages can be marked; and those 
are cases which, for want of being aware of the cause, or want 
of careful observation, appear mysterious, equally to the patient 
and the practitioner; often leading to bad practice, and very often 
also, as in similar remittents, subjecting the former to the charge 
of nourishing imaginary diseases. 

When the paroxysm is more palpably a febrile one, the irre- 
gularity is sometimes such, that the whole may be, or appear to 
be, a cold fit; neither heat nor sweating appearing; and such cold 
fits will even last for twelve hours or more. In other cases, an 
endless number of cold and hot periods will occur, as if twen- 
ty or thirty paroxysms had been condensed into one period; 
while in others again the whole is a hot fit, or, as also happens, 
a mere period of sweating, or of a tendency to this which is 
roused on the slightest exertion; the preceding portions or stages, 
if they really occur, being insensible. And thus also a tempo- 
rary or diurnal variation of the pulse is sometimes the only pal- 
pable appearance, at least in a patient not given to complain of 
moderate inconveniences, or not morbidly alive to his own feel- 

in s s - 

Particular cases without end could be described in illustration 
of these states; but if amusing to a certain class of patients or 
readers, it would be a useless labour in a scientific view. 
Among such, will be found the endless strange cases known in 
America by the name of dumb ague; as they would include also 
much of the history of the common people, as well as of their 
betters, in the countries especially exposed to these diseases. 
But a subject fertile almost to romance, must not be indulged in, 
where enough remains of what is necessary, to occupy both the 
writer and the reader for many further pages. « 

If the cases which may be ranked under the preceding gene- 
ral sketch can always be assigned to their true cause, witli mo- 
derate attention and a due knowledge of this disease, it is less 
easy to judge truly, or rather the errors are chiefly committed. 
when some one symptom is very distinguishable beyond the 
rest; and most of all, when these are of a local nature, or when 
they are accessaries rather than essential parts of the disease. 
The former cases might be distinguished by the two terms ob- 
scure and anomalous, were it necessary, or were it indeed al- 



158 OBSCURE INTERMITTENT^. 

ways possible, to define the limits, in practice, under words the 
sense of which is apparent: the latter may also be sometimes in- 
cluded under the term anomalous; and they become the simu- 
lating cases of this chapter, when, from the absence or obscuri- 
ty of the periodical fever, and from the marked and important 
nature and prevalence of the attached symptom, they are liable 
to be mistaken for separate or original diseases. Were I more 
largely in possession of such varieties, I might have attempted 
to classify them under those separate terms; as it is, I could not 
do this to any purpose, and shall therefore describe those which 
I have seen, without any pretence to order. And if I have 
been obliged to reserve some of those for a separate considera- 
tion, because of their having been erected into separate diseases, 
the reasons which have thus compelled me will hereafter be ap- 
parent to the reader. 

In commencing this examination, I must even confound in 
some measure what must be considered as effects of the inter- 
mittent, with what appear to be symptoms or modes, because 
of the light which the one set throws on the other; being sensi- 
ble of the inexpediency which I could not avoid, of separating 
the, paralytic symptoms of those diseases, from the paralytic 
consequences which succeed to other and different symptoms. 

It is a noted fact, that it is the effect of chronic or habitual 
intermittents to injure or destroy the intellectual faculties, as I 
had occasion to point out already when treating of remittents. 
This is notorious in the countries where these disorders prevail, 
and very remarkably, as I formerly said, in the Maremma of 
Tuscany, where even absolute idiotism from this cause is com- 
mon; the fact being marked, even to cursory travellers, by that 
apathy, listlessness, or indolence of mind, gradually approach- 
ing to fatuity, which I formerly described. If the cause be ob- 
scure, it cannot well be more obscure than every thing else 
which belongs to the action of Malaria; while the fact of the 
universal influence of this poison on the nervous system, local 
as well as general, leaves no difficulty, at least in believing that 
it may produce such effects on the mind. 

It seems to me that there is here an analogy between the lo- 
cal and the general diseases of the nervous system, worth no- 
ticing; but whether it is much more than a coincidence, whe- 
ther there are really analogous causes for these analogous effects, 
it would be now impossible to decide; as it may almost be thought 
presumptuous to suggest. 

In the intermittent, as a new disease, or for a long period of 
its existence, as sometimes happens in the chronic or mild re- 
mittent formerly described, the effect which the mind under- 
goes is chiefly a state of irritability, or a condition generally, 
which may be considered to belong to excitement, if we can 



OBSCURE INTERMITTENS. 159 

venture- to use so vague and abused a term; or to consist in a 
susceptibility to pain, or in an increase of sensibility. Every 
thing marks this state of things: the peevishness, the false and 
exaggerated views of evil, the morbid excitement of the mind, 
extending even to the intellectual powers, and sometimes even 
with good effects, as I formerly observed, as far as certain of 
their actions are concerned, and lastly the increased sensibility 
to bodily suffering; to say nothing of nervous sensations be- 
yond numbering. But in its progress, the opposite effect gene- 
rally takes place, or the mind is found to be benumbed; and 
hence, among many other appearances, that striking listlessness 
and submission to the present evils, that total want of even a 
wish to escape them, which is so striking a feature in the mass 
of people in countries subject to Malaria and its diseases. Thus 
also, in single cases, even in our own country, the same effects 
take place from a long continuance of the disease; while debili- 
ty of mind, proceeding even to absolute fatuity, sometimes oc- 
curs, and especially if to this be added the injudicious interfe- 
rence of physicians, by means of blood-letting and other debi- 
litating remedies. That such a condition amounted at times 
even to an insensibility to bodily injuries, I remarked formerly 
on French authority; while what I have now said explains fur- 
ther the apparent contradictions on this subject. 

That this disease produces an insensibility to pleasurable im- 
pressions, if I have but recently mentioned it, is a fact too re- 
markable in its results not to be noticed here as a part of the 
general illustration of this condition of the nervous system. 
Nor is that consequence a secondary one, originating in false or 
perverted moral views, or in an aberration of the reasoning fa- 
culties; since it appears, on the contrary, where that does not 
exist, or to be, absolutely, an insensibility, or a primary disor- 
der, in the nerves of those organs of sense, which are the me- 
diums of pleasure. I cannot doubt this, from the facts related 
to me by patients thus suffering, and who were at the same time 
good metaphysicians; those facts and their complaints being, 
that beautiful objects, such as pictures, natural scenery, and so 
forth, which, before that, or when in health, had been most 
pleasurable or engaging, seemed to make no impression at all, 
on the sense; and not because their minds were affected, because 
these things were viewed under a state of mental anxiety or de- 
rangement, since that state of mind was not present, but sim- 
ply from failing to make the usual and expected impressions. 
From such patients I have received also the same complaints 
and statements, with respect to the other usual causes of simple 
pleasurable feelings; and very particularly from those who, as 
musicians, were accustomed to delight in music, not less from 
science than feeling; those being, that they seemed to suf- 



160 OBSCURE INTERMITTENTS. 



fer under a positive insensibility as to what used to be 
source of the most refined delight, although labouring under no 
affection of the temper, nor any of those sensations commonly 
called hypochondriacal. And thus have others complained that 
the most grateful odours had ceased to give pleasure, that the 
scent of a rose was not only powerless, but produced absolute 
pain by reminding them of what it once was; while every at- 
tempt to revive the former associations connected with this and 
other similar objects of delight, was unavailing. And what 
perhaps will illustrate this condition still more strongly, though 
it may possibly excite a smile, was the complaint of one of these 
patients, deeply in love, that in this state of disorder, the touch 
of the hand of the fair object, which used formerly to reach his 
heart, appeared no more to him than the contact of his own or 
of the most indifferent person's. That all this has been bitterly 
complained of as adding deeply to the torments of this disease; 
by those who were conscious or informed of the cause, and who 
were at the same time persons of refined taste, education, and 
feelings, it is almost unnecessary to remark. 

Now, "mutatis mutandis," this is precisely the progress in 
those cases where single nerves are affected, instead of the whole 
cerebral system, or when such local affections are severe in pro- 
portion to the general one. In the Neuralgia, the first action 
of the cause is an increase of sensibility reaching to the highest 
imaginable degree of pain, and indicated further by numerous 
symptoms which will be more fully pointed out hereafter. But 
the progress of this is to palsy; or the excessive sensibility is 
succeeded by a diminished one, as if, in this case, as well as in 
the former, the sensibility had been exhausted by previous over 
exertion or over excitement. The former may be considered a 
succession of effects as to the whole nervous system, correspond- 
ing to that which, in the latter, occurs in a single nerve, or in 
a single portion of one. And what tends still further to confirm 
this view is, that if the debilitating or evacuating system of phy- 
sicians accelerates or augments this effect in the former case, or 
as to the whole brain, so does the very same practice produce 
the analogous effects as to the single nerve; as it is thus that the 
paralytic symptoms which might otherwise be long in taking 
place in Neuralgia, are accelerated or increased. If this analo- 
gy is as well founded as it appears to me to be, it is not only 
curious as a question of pathology, but it serves to confirm the 
views hereafter deduced from other arguments, respecting the 
true nature of these local diseases and their connexion with the 
causes of intermittent. I need scarcely remind the reader of 
the analogous fatuity, formerly noticed, which occurs as a con- 
sequence also of remitting fever, and most generally under simi- 
larly improper treatment. The facts are in reality the same, and 



10 



OBSCURE INTEKMITTENTS. 161 

so are the general causes and conditions; though some variations 
of effect take place, proportioned to, or depending on, the dif- 
ferences that are found in these two varieties of marsh fever. — 
And if I have here been compelled to separate these consequen- 
ces, and to treat of them in two places, not avoiding therefore 
some repetition, and disjointing a subject which I would gladly 
have brought under one general view, this has all arisen, like 
much more of similar inconvenience, from having been com- 
pelled to follow the usual practice of physicians, in separating 
these associated diseases, or rather these two varieties of one 
disease. 

Did I think that any specific evidence on this subject was re- 
quired, I could easily relate many individual cases of debility of 
mind, and of a state of almost ultimate fatuity, occurring from 
the action of chronic intermittent; and what is perhaps even 
more important, some very striking ones, in particular, of the 
effect of blood-letting in producing this consequence. I dare not 
prolong these pages for the former purpose; since what I have 
said, being a deduction from facts and cases, could receive no 
further support from the cases themselves? yet I will note one 
or two briefly which relate to the latter fact, because of the very 
marked nature of the action of the misapplied remedy. 

The first of these was a patient who had been subject to re- 
peated attacks of quotidian, in successive years, under my own 
eare, while a vigorous and intelligent young man of twenty -five, 
in the upper ranks of life. In a subsequent and similar attack 
during my absence, it was the fancy of his physician to pre- 
scribe blood-letting within the first days of the disease, under 
some erroneous view of its nature. No very obvious conse- 
quence followed the first operation; but on the second, it was 
remarked that he ceased to complain as he had done, which ap- 
peared to give the temptation to a third trial; immediately after 
which he fell into a state little short of idiotism, while the quo- 
tidian became also attended with many anomalous symptoms. 
Thus I found him, and just in time to prevent a fourth bleeding, 
which would probably have produced an extension of these con- 
sequences, and might easily have terminated, as I have more 
than once seen, in palsy, epilepsy, or death. The disease was 
cured in the usual way, by bark; but the debility of mind was 
not removed for six months, while I have reason to suspect that 
it was even much more durable. If such effects have not been 
oftener, it is probably from the much greater predominance of 
this disease in the lower classes, where such mental consequences 
would attract little notice, or where the general neglect of the 
mental faculties, and the slender uses to which they are applied, 
would render such consequences insensible. 

In another case, which I could watch, but had no opportunity 

21 



162 OBSCURE INTERMITTENTS. 

of treating, the history, and the age, were similar; but, in the 
paroxysms, this patient, himself a military surgeon, was tor- 
mented by headachs. Successive blood-letting and cupping, on 
the usual principle, brought on at length fatuity, but so slightly, 
that after a few weeks from each bleeding, he began, on every 
occasion, as he does yet, if more slowly, to recover his intellects. 
With that, he also recovers some complexion, with a return of 
strength and appetite; but whenever a casual headach returns, or 
if an imagination naturally rendered morbid, in his physician, 
possibly, as well as himself, conceives that there is about to be 
another " flow of blood to the head," he is again subjected to 
blood-letting, and again becomes a mere infant. What the final 
result may be, it is not difficult to foresee. 

I should now add, that while I have made a considerable 
search into authors, on this point, I have had little success in 
discovering cases or remarks by which to support the opinion, 
that this consequence was the frequent result of similar and im- 
proper treatment, while there is no want of evidence of the 
mere fact as connected with intermittent: the former opinion, 
like most others in this work, being derived from my own ob- 
servations. Whatever suspicions I may entertain as to some few 
not sufficiently positive to quote, they are better left to the 
judgment of others: though from what I do read in modern 
books, I entertain no doubt, that, in this, as in remittent, the 
depravations of intellect so common, in chronic cases as after 
acute ones, have been the result of an improper practice; and if 
this is not to be deduced in so many words from the narrators 
themselves, that is a circumstance of which the causes are too 
obvious to require explanation. Whether the ancient and foreign 
writers who have often so well illustrated the anomalous inter- 
mittents, have been unaware of this frequent consequence, or 
have overlooked it, or explained it in some other manner, is what 
I cannot decide: but I am pleased to find at least one high au- 
thority, and equally distinct, in Sydenham, when he remarks, 
that fatuity is not an uncommon effect of tedious intermittents, 
and very particularly where evacuations have been excessively 
or improperly used. Hence, his Amentia Quartana; since it 
seems to have been under that variety chiefly that he had seen 
this consequence. 

It would also appear that mental disease of a more severe 
character may be produced by these causes; or that it may occur 
in so early a stage of intermittent, that we ought, perhaps, rather 
to refer it to the cause of that disease, than to the disease itself 
as a cause of the second order; while, occurring at a later one, 
it may be supposed a consequence of the previous operation of 
the fever on the nervous system, as happens with respect to fa- 
tuity. In the former case, the analogy would be to apoplexy as 



OBSCURE INTERMITTENTS, 163 

the primary attack of Malaria, and the disorder thus produced 
would be an anomaly, or a purely simulating case, as the latter 
must be classed with consequences. Had I been in possession 
of more cases, I might have distinguished and separated these 
circumstances, as I might also have investigated the whole sub- 
ject to more purpose: but under such a poverty of facts, I must 
content myself with much less, leaving what I cannot better 
illustrate now, to a day of further information. 

I allude to mania; though it is a somewhat obscure question, 
since, in ordinary mania, where there is no reason to suspect 
this cause, the exacerbations are sometimes regularly periodical. 
I do not wish to go deeply into a subject which appears to me 
to stand very much in need of elucidation, and must, therefore, 
request my readers to examine carefully such cases of this na- 
ture as they find on record, or may occur to them in practice; 
while it would be proper that this suspicion should be better 
known to practitioners at large than it appears to be, since I 
have seen four cases at least of absolute and pure mania, of most 
distinct tertian and quotidian forms, which, from this ignorance, 
as it appeared to me, became the subjects of gross mistreatment. 
The exacerbations were, in all, as distinct as those of a common 
intermittent would have been, and as regular, while the two 
tertian cases left a day intermediate of the most entire sanity of 
mind: the period of the paroxysm being a perfect mania, and 
not a febrile delirium, and while, in fact, no marks of fever 
could be discovered. And in one of these at least, the cause was 
as easily as it was distinctly traced; since the disorder had com- 
menced as a common tertian, which seemed to have entirely dis- 
appeared to be exchanged for the mania: while of the other, 
whatever my suspicions were, I could not procure a distinct pre- 
vious history, from the inattention and ignorance of the friends 
and the patient. In the quotidians, not only were the accessory, 
if obscure, symptoms of intermittent to be found on an accurate 
inquiry, in both the cases, but while the original cause, in one 
of them, was distinctly traced, so was the truth of the conclusion 
confirmed by the success of the method of cure which was adopt- 
ed, after great maltreatment. 

As to one of the quotidian cases just noticed, like some other 
examples of similar mania which have occurred to me, I feel 
incompetent to decide whether it was connected with inter- 
mittent or Neuralgia, since I could procure no sufficient infor- 
mation respecting the previous history. But while, as will 
hereafter be more apparent, I do not consider the distinction of 
any moment, I think it possible, that although such a mania 
may be the replacement of some intermittent or neuralgic dis- 
order, arising as it does, in or from both those forms of disease, 
as well in their natural course as from improper treatment, so it 



164 OBSCURE INTERMITTENS, 



might also constitute the primary attack, or be the first and sole 
effect of the cause. There is no want of analogy to support such 
a view. The primary attack of Malaria is sometimes in the form 
of delirium, or absolute mania, as, in other cases, it is in that of 
apoplexy; and instances of this, even to an epidemic extent, are 
noted by various authors. The primary attack of Neuralgia, 
also, as well as of intermittent, is sometimes palsy without pain. 
And since cold will produce palsy or fatuity, primarily, since 
fatuity, palsy, and mania, are but analogous or connected states 
of the nervous system, as I shall hereafter attempt to show, it 
is as possible to conceive that mania should be the immediate 
and sole result of the cause of Neuralgia or intermittent, as that 
this should be palsy or fatuity. 

And this argument from analogy is supported by facts: since 
among other cases, Vandermonde describes an intermittent ma- 
nia, or delirium, of two months' duration, which was cured by 
bark, having been all along without any febrile symptoms, 
Whether a periodical mania, termed lunaris, and described in 
the Ephemer. Nature Curiosor. may be quoted as another ex- 
ample in support of the same view, I am not willing to decide. 
But it is evident that whether we suppose the cause, or the dis- 
ease, to be Neuralgia or intermittent, it does not affect this argu- 
ment: inasmuch as wherever the action is local, it may, under 
different modes of viewing the disease, be ranked with either. 
As to a mania dependent on intermittent and following it, there 
is a confirmation of that fact, and on a very large scale, by Me- 
zeray. In this case, as in those of fatuity just quoted, the acces- 
sary or secondary cause was similar maltreatment, or the abuse 
of evacuations: but the result, which occurred in great numbers 
of people, was a perfect mania, or a durable phrensy or delirium 
without fever. It is scarcely, indeed, more difficult to compre- 
hend how this should happen than fatuity; since the conditions 
of the nervous system, or brain, in both cases, cannot be very 
remote in kind. 

To pass from these subjects to one of a very different nature, 
that nosology, to which I have so often referred, and which, be 
its logic even as faulty as has been said, far surpasses in real 
value the whole of its competitors, has enumerated a variety of 
intermittent under the term emetica, referring it, however, to 
tertian. It is very necessary to notice this particular anomaly, 
on account of the errors to which, like all other anomalous cases, 
it gives rise, and further, because it occurs under the quotidian 
type as well as the tertian, to whatever variety in these fevers 
that return may be long. 

I have already remarked, that the ordinary paroxysm of an 
intermittent sometimes terminates in vomiting, while nausea 
also occurs in these as in the chronic remittent often very dura- 



. 



0-BSCURE INTEKMITTENTS. 165 

ble, and forming a very distressing addition to the other symp- 
toms. In the case to which I would here especially call attention, 
and which are the chronic ones, the vomiting becomes the most 
conspicuous symptom, or even the only one which the patient 
may notice; when inattentive practitioners are subject to mistake 
it for an original disease, dependent on some mysterious cause, 
or to assign a wrong one to it. 

It is true that there occurs, and in females almost exclusively, 
a disease of this nature, of an original or separate character, and 
which must not be confounded with this; while the distinction 
is always rendered perfectly easy by the periodical returns of 
the disorder, under review, and, to a careful observer, by the 
presence of some other symptoms of chronic intermittent, how- 
ever slight, or by the alternating of this one with some other 
symptom, or lastly, by inquiring into the previous history of 
the patient. I must also remark, especially, that it is very com- 
monly preceded by a state of drowsiness, of which it is the ter- 
mination. It is, in reality, in all the cases where it occurs, the 
real termination of the paroxysm, as in the well-marked inter- 
mittents; though that may be so slight as to produce little incon- 
venience to him who, long accustomed to this disease, does not 
know what health is. Thus at least has it appeared to me; but 
considering how often the stomach appears to be the principal 
object of attack in all the fevers of Malaria, I can also conceive 
that it is a real misdirection of the febrile paroxysm, just as that 
is sometimes misdirected to the heart, or as it produces the va- 
rious affections classed under Neuralgia; while the possibility of 
what I here call a misdirection, in chronic cases, is illustrated by 
what happens in the black vomit of remittent, and in the inflam- 
matory affections of the stomach occurring in all the severe marsh 
fevers, of whatever type or form. 

Those who may hereafter have opportunities that have not 
occurred to myself, will easily, with this hint, discover how the 
fact really stands. I need only add, that as far as I have seen, 
this vomiting is very transitory; occurring whether the stomach 
is full or empty, and, when past, leaving it without any derange- 
ment, or rather being the immediate forerunner of the interval 
of temporary health. And, when its period is arrived, the 
slightest cause, even a glass of water, will bring it on instantly; 
while it also comes on at times with so little previous notice, 
that the patient has not even time to leave his seat, or change 
his position. Thus have I seen it continue for three months: 
being either removed, only by the cessation of that particular 
relapse, or else becoming exchanged for some other local symp- 
tom. When it thus occurs in cases of Neuralgia, as is also the 
fact, the explanation is now rendered easy; while it confirms, 
if that could need confirmation, the views here entertained vt 



166 OBSCURE INTERMITTENTS. 

that disease. As to remedies, its cure, it is plain, must be sought 
among the general remedies of chronic intermittent; while I 
may add that the ordinary kinds of medicines in use by that 
class of practitioners which sees nothing beyond symptoms, 
serve only to accelerate the period which they can neither pre- 
vent nor cure. 

I formerly remarked that hysteria, or nervous affections such 
as belong to that disease, sometimes occur periodically, or other- 
wise, in remittent; and thus also are they found in the chronic 
quotidian, as well as in the tertian and quartan, where this va- 
riety is noticed by nosologists. These cases are occasionally 
very troublesome; and that they should be obstinate, is to be 
expected from the inveterate nature of these chronic diseases; 
while such obstinacy must also often depend on the ignorance 
or error of the practitioner as to the true cause. The symptoms, 
whether for number or intensity, may be any or all of those 
which belong to this Protean disease; while I must remark also, 
that the periodical vomiting just described is sometimes united 
to them, tending, as I have seen, still further to mislead the prac- 
titioner unaware of the nature of these obscure intermittents. 
Thus also may one slender symptom alone occur: and in this 
manner have I seen the globus hystericus, in males as well as 
females, returning at daily regular periods, and enduring for 
many months, nay, like the disease in other forms, even for 
years; while its true nature was proved by its becoming ex- 
changed for another anomalous symptom, and by the previous 
history of the patient, as well as by the mode of cure. 

I can give no other direction for distinguishing this hysteria 
than what I have already given as to the vomiting, and as to the 
whole of this chronic intermittent; but while I need not also 
point out any other than the general mode of cure, I must cau- 
tion practitioners against blood-letting, because it has been often 
recommended and often practised in these cases: and with the 
result which it invariably has, in every case and variety of chro- 
nic intermittent, of aggravating the disorder, or of inducing 
new symptoms, and, finally, of destroying the patient's health 
for ever. 

If I am, myself, inclined to consider the palpitation which is 
one of the most remarkable and the most distressing of the ano- 
malous symptoms or forms of chronic intermittent, as a Neural- 
gia of the heart, as one of those local misdirections of this dis- 
ease which, affecting other nervous organs or separate nerves, 
produces those very marked disorders, and if therefore my own 
desire would have been to have ranked it with those, and thus 
to have deferred it at present, I am fearful of giving more cause, 
by these new views, for that incredulity and those objections 
which I foresee, I shall therefore treat of it here as a merely 



OBSCURE INTERMITTENT:?. 167 

anomalous symptom of chronic intermittent; reserving to my- 
self the privilege of a different and better classification, when 
the alarm at these novelties shall have subsided. 

The modes, as to the patient's feeling and as to the recurren- 
ces, in which the heart is affected in these cases, are so various, 
that I must examine them at some length: a proceeding which 
becomes absolutely necessary, from the almost universal errors 
on this subject, from the pertinacity with which these cases are 
maintained to be independent nervous affections, or are referred 
to organic derangements that have no existence, and from the 
consequent maltreatment of the patients; to which are too often 
added alarm and anticipations, materially aggravating a disease 
which is in itself sufficiently distressing. 

Increase of the velocity or of the strength of the circulation^ 
or of both, attended by an increase in the force of the blow 
given by the apex of the heart, is the most simple of these affec- 
tions, while this may be merely sensible to the patient himself, 
or else may be visible to a bystander. In other cases, that in- 
crease of action is attended by irregularities in the force; or there 
are occasional palpitations, of short duration, but repeated; or 
they are sometimes limited to single starts or spasms, or else 
there are intermissions under every irregularity that can be ima- 
gined. These disordered actions, which must be felt to be un- 
derstood, are often attended with the most distressing sensations 
in the brain and in the whole system, affecting even the mind in 
various ways; producing among other things uncontrollable fear 
or inexplicable alarm, and sometimes seeming to threaten imme- 
diate death. When of any duration, they also often leave the 
patient exhausted, as if from the excess of fatigue; and this, con- 
stituting an inexplicable derangement, often lasts during a whole 
day, or long after the palpitation has ceased. In the heart itself, 
among other strange sensations, it is not uncommon to feel as if 
it was grasped by a hand, and compressed; while there is some- 
times also the sensation of its being paralyzed, or about to cease 
from motion altogether. In other instances, and in the mildest 
cases, the affection is no greater than that which commonly at- 
tends fear, or that peculiar and slight alarm which may occur, 
for example, in a timid or anxious speaker about to rise in pub- 
lic; and, apparently in consequence of association, it is the effect 
of this to produce alarm, or fear, or anxiety, for which the pa- 
tient, aware of its real cause, can find no reason, but which ano- 
ther, ignorant of this, or morbidly active in seeking for moral 
evils, easily refers to events or circumstances in life that are 
dreaded or anticipated. Or, as will be very obvious, the prin- 
ciple of association produces, by inversion, the passion or feel- 
ing which, in the ordinary cases, excite these peculiar actions of 
the heart. Hence it is, that to be aware of the nature of this 



168 OBSCURE INTERMITTENTS. 

disorder, is important to the patient; as, by explaining to him 
the true cause, it will prevent him from seeking for imaginary 
evils that will aggravate his sufferings. 

Such are the more ordinary forms of this palpitation; and how 
often it has been referred to enlargement of the heart, to ossifi- 
cations, and so on, I have seen in but too many instances. But 
I must also remark, that this diseased action sometimes takes 
place in the inferior aorta, as well as in the heart, or is occasion- 
ally transferred from this organ to the artery; constituting an af- 
fection well known to occur in what is called dyspepsia, which, 
for aught I know, may depend on many nervous diseases, but 
which, as before observed, I have often most clearly traced to 
the class of disorders under review. I need not remind the 
medical reader of the description of this particular disorder given 
by Dr. Baillie; nor ought I to pretend to conjecture the cause- or 
causes as it did occur to him; but while I have traced it to the 
cause under review, I am bound to add that this inference was 
drawn from observing that it alternated in relapses, and indeed 
in periods of long duration, with a palpitation of the heart de- 
pendent on intermittent, and itself alternating with relapses of 
common quotidian, as well as with the intermittent periods them- 
selves, in a case of long standing subject to many other anoma- 
lies. 

If the real cause of these affections of the heart be often ob- 
scure, there ought never to be any difficulty in ascertaining their 
nature when any other symptoms of chronic intermittent are 
present, when the patient is constitutionally subject to this dis- 
ease, or is known to have suffered formerly from it, or when, as 
frequently happens, this affection alternates in any manner, with 
any of the ordinary, or of the anomalous symptoms of intermit- 
tent. These form the easier grounds of judgment to the physi- 
cian, often as they are all overlooked; and in these several modes 
do those derangements of the heart often occur. 

Presuming that the disease is regular in its returns, and con- 
nected with obvious intermittent, the palpitation, as far as I have 
observed, belongs to the same period of the paroxysm as the cold 
fit, or generally so; while in cases where it is the only symptom 
or the only very visible disorder, it has equally appeared to me 
to be the substitute for this. Thus also, when slight, it may 
usher in the paroxysm, subsiding in a short time; and here it 
corresponds with that general and common affection of the cir- 
culation which attends the commencement of the diurnal fit. 
The duration of a paroxysm of this kind, like the violence, is 
consequently variable; extending from an hour or less to twelve 
or more; possibly, in such cases, occupying the entire time of 
what would be a paroxysm in the common intermittent: and I 
have met with one instance of a double quotidian form, in which 



OBSCURE INTERMITTENS. 16<J 

the two returns left very little repose to this organ during the 
twenty-four hours, and in which the patient was nearly depri- 
ved of all sleep, procuring it only during the very short inter- 
vals. This case, after lasting three months, while sentence of 
condemnation had also been passed against the patient, under the 
supposition of a disorganized heart, was cured in two days by 
the remedies of intermittent; proving clearly that the judgment 
which I had formed respecting it was correct. 

Supposing that the returns of palpitation are regular, whether 
in the quotidian or tertian form, and further, if the duration of 
the attack is also limited, I have stated a case that ought never 
to leave a moment's doubt to the physician, even though there 
were no other symptoms of intermittent present. But it will 
often happen that there are others, such as an indication of a 
previous cold stage, or rather of its commencement; and that 
stage, if not marked by absolute coldness, being distinguishable 
by an acute eye, in the physiognomy of the patient. It is also 
not uncommon for it to be accompanied by a state of drowsi- 
ness, which, while it is evidently the coma of intermittent, is 
often, or perhaps always, mistaken for a derangement of the 
brain produced by that of the heart, and which thus leads to the 
erroneous and destructive practice of blood-letting, founded on 
the vulgar and not less fashionable dogma of " a flow of blood 
to the head. 7 ' 

I do not, myself, conceive that this disorder, the intermittent 
of the heart, or, as I would call it, the Neuralgia of the heart, 
can .ever exist without some of the collateral symptoms of chro- 
nic intermittent, which I need not now repeat; being, I believe, 
attached to the chronic varieties chiefly, or being a chronic, and 
not an acute disease, as are, I believe, all the Neuralgias, any 
more than I can conceive any Neuralgia, however local and li- 
mited, so unattended, while I have assuredly never seen such a 
case. But if I say that all Neuralgias are chronic, it is not that 
I suppose this a necessary part of their nature, or that they may 
not be transitory as well as intermittent. This however will be 
proved, or not, hereafter, when they become better known and 
better treated: and in the meantime, as far as they are such, it 
ought to be plain that this may be the consequence merely of 
ignorance and maltreatment, suffering the disease to establish 
itself and thus assume that character. 

But the disorder under review may appear to be unaccompa- 
nied by such symptoms, to a careless or hasty observer, or to 
a practitioner, generally ignorant, or ignorant of the true nature 
of this disease, or to one who adds prejudice to want of discern- 
ment or knowledge; as is notedly true respecting common Neu- 
ralgias, in which this connexion is almost always overlooked, 
and where, had it not been so neglected, the theory and the prae- 



170 OBSCURE INTERMITTENT?. 

lice too for that disease could not have so long been that discre' j 
dit to physic and physicians which it has been. And as it is 
subject to many irregularities and obscurities, these irregulari- 
ties, should it be so mistaken, as in fact it has always hitherto 
been, not merely tend still further to confuse the judgment of 
the practitioner, but afford him reasons for persisting in his er- 
rors, and further, for disputing the views here held out. I shall 
hereafter notice another ground of erroneous judgment, arising 
from the term rheumatism of the heart, and from a false deci- 
sion as to that disease. 

It becomes necessary therefore to describe these irregularities? 
and, as far as possible, to explain them; though I must limit my- 
self to what I have seen, and to my own powers of explanation; 
finding no assistance whatever from the writings of others: not 
even a single case, such as I have fortunatel}* - been able to ex- 
tract on some of these subjects, from authors, in support of my 
own views. 

It happens that the fits of palpitation are interrupted, as I 
have just remarked; and the analogy, in this case, will be found 
in those intermittents where the common paroxysm is similarly 
irregular, or where there is an intermixture of numerous cold 
and hot stages in one paroxysm. If there are two fits in a day, 
it may be a double quotidian form, such as I have just described; 
while it is plain, that if regulated by the other complicated 
types of intermittent, there is scarcely an irregularity which it 
may not exhibit. If it is irregular in ways not reconcilable to 
those cases, its analogy will still be equally found in those chro- 
nic intermittents which consist in irregular returns, of an end- 
less variety; while, if only occasionally produced, and by some 
cause inducing debility, irritation, or perhaps mental affections* 
we have precisely the same appearances in the common chronic 
intermittent. And thus, in fact, do the fits of palpitation fre- 
quently occur, in patients who have been infested with chronic 
intermittents; single attacks, lasting perhaps for a few hours, not 
to recur for some weeks or months, and often traceable to a 
marked cause. 

I will not extend this class of irregularities, nor need I dwell 
further on this analogy as affording the explanations. It is ob- 
vious that there may be others, if I have not seen them; but the 
physician in possession of the grounds of reasoning can rarely 
be at a loss in explaining them to his own satisfaction. 

One other mode and cause of irregularity must however be 
pointed out; because, while it is needful to be known, it belongs 
to the proofs of the nature and cause of this disease. In this case, 
when the palpitation disappears, it is to be replaced by some 
other local symptom or anomaly, or else by a perfect intermit- 
tent, or by some irregular and partial form of this* In practice, 



OBSCURE INTERMITTENTS. 171 

liere, the error is to suppose that the palpitation is a disease of 
itself, distinct from the others, be those what they may; that 
the patient, for example, has a disorganized heart; and an inter- 
mittent also, or some other disorder, or that the whole are 
symptoms of some nervous disease. A more careful observer, 
or one at least who is acquainted with this subject, will however 
perceive that if the palpitation yields to an intermittent, it is be- 
cause the disorder has changed its character; or that if vomiting, 
or hysteria, or diarrhea, or any other of the symptoms so often 
mentioned, appear when this retires, it is because the local action 
of the chronic intermittent has taken a new direction. And thus, 
by watching, does he learn to explain what appeared to him un- 
der a false light, and to regulate his practice accordingly. 

The other class of irregularities occurring in these palpita- 
tions, demands a different explanation; since, as far as I can per- 
ceive, these do not admit of one from any analogy deduced from 
intermittent, while they seem to be illustrated by what occurs 
in the other local and similar affections, or in common Neural- 
gia. 

They are all referrible to the effects produced by external or 
adventitious causes, such as exercise, position, or any thing 
which may interfere with the ordinary actions of the heart. 
Thus, while a fit of palpitation can sometimes be removed by 
various means, so is it irritated, or augmented, or prolonged ; while 
these facts tend to mislead the practitioner as to the imagined 
cause and nature of the disorder, as they may also afford arguments 
to those who are unwilling to admit the explanation which I 
have here given. I may state the most extraordinary case of 
this nature which ever occurred to me; because while it had 
been determined that organic and incurable disorder was pre- 
sent, it vanished suddenly on the appearance of an intermittent 
quotidian, which was soon afterwards cured. 

In this case, the patient had no relief from the palpitation, 
which was both incessant and violent, except in the erect pos- 
ture, when awake, while it returned instantly on sitting down, 
and while, frequently also, it could be removed only by walk- 
ing about the room, in which manner he was compelled to pass 
nearly the whole day. Thus also, at night, was it instantly 
produced by attempting to lie down; so that the little sleep that 
was procured, and not till after urgent necessity, was to be ob- 
tained only by being bolstered up as erectly as possible. 

It appears to me that the explanation, here, is to be derived 
from the analogy of common Neuralgia, where it is well known 
that external irritation will prolong or re-excite the fit of pain, 
as it is notoriously also increased and prolonged by exercise or 
use of the affected part, as happens in a very marked manner in 



172 OBSCURE. INTERMITTENTS. 

sciatica, and as also occurs in the "Tic" of the face on attempt- 
ing to eat. 

I perhaps need scarcely now suggest to medical readers, 
how easily a disorder of the heart of this character might be con- 
founded with that affection which Dundas has described under 
the term Rheumatism of the Heart. The symptoms, ostensi- 
bly, are the same, and may, in every respect, resemble those 
which he has described, even as relates to their violence; since, 
in reality, scarcely any conceivable appearances of disease could 
exceed those which occurred in the case that I have just de- 
scribed, or any variety of distress and of feelings as to the pa- 
tient, or of symptoms to the practitioner's observation, be pro- 
duced by the uttermost disorganization, which did not occur in 
this case. And it is also plain, that the fact of the occurrence 
of a local, or, as it happened also in this instance, of a more ge- 
neral chronic rheumatism, alternating with such an affection, or 
preceding, or following it, while both were but localizations of 
the chronic intermittent, would tend to confirm this error, and 
possibly, lead to considerable evil, in consequence of a misap- 
plication of remedies. Nothing can however be more plain, 
than that the disease recorded by Dundas is of a very different 
nature, as the dissections prove; while, respecting the present, 
equally violent in apparent character, rendered singularly de- 
ceptive also by the concomitant circumstances, there can be no 
hesitation; inasmuch as this patient survives after twenty years 
from the attack. And while I suspect that the disorder which 
I have described has actually been often thus mistaken for this 
far more serious disease, as it assuredly has for organic affec- 
tions of the heart generally, I cannot help suspecting, also, that 
the case recorded by Pemberton, and appended to the descrip- 
tive paper in question, had actually been one of this nature; 
though more willing to leave that to the discretion of my 
readers, after they shall have compared the facts there narrated, 
with the description which I have given of the palpitation de- 
pendent on intermittent. 

Before quitting this particular case, I may yet remark, how 
easily the impression made by the record which I have here ex- 
amined, may have assisted in impeding a proper inquiry into 
the nature of this disease as I have described it. It is sufficient- 
ly apparent, also, how error would still be produced by a par- 
tial observation which, while it saw that this palpitation alter- 
nated with rheumatism in some external muscles, should not 
perceive that it alternated also with other affections, as 1 have 
just pointed out; and further, did not remark that this rheuma- 
tism was itself a periodical affection belonging to intermittent, 
or a species of Neuralgia. On this I shall speak more particu- 



OBSCURE INTERMITTENS. , 173 

larly immediately; but it will now be plain how much the views 
here held out simplify the whole history of these disorders, by 
assigning one general cause productive of numerous local ac- 
tions, and generating diseases therefore which depend for their 
visible characters on the peculiarities of those organs: diseases 
misleading those who look only to obvious symptoms, or are 
unhabituated to philosophical generalizations and abstractions. 

The proofs of the truth of the view of these palpitations, thus 
given, are now sufficiently apparent not to require a formal enu- 
meration; but on this subject I will sketch one case, because it 
was in itself such as to include almost every one of these va- 
riations. If I have avoided loading this essay with ordinary 
cases, I must still claim the privilege of describing such as of- 
fer illustrations, which, while they are perfect, can be comprised 
within a small space. 

In this patient, the palpitation was of the most severe cha- 
racter, and had lasted for some months, occupying a large part of 
every day, or recurring in successive fits, but without any great 
regularity, and always increased by irritations of various kinds. 
It was of that kind and character which seemed to justify the 
belief in an organic disease, as far as this ever can be conjec- 
tured: while there were no marks of temporary fever, or of any 
other derangement, to be traced, and while the patient was even 
robust, and, when not suffering extremely from the fits, capable 
of all the usual occupations of a very active life. After much 
cross-examination it was discovered that he had for many pre- 
vious years been subject, annually, and nearly always at the 
same periods, commencing with the end of summer, to dif- 
ferent diseases; being in one season, periodical toothach, in ano- 
ther diarrheas, in a third rheumatism, and in others, anomalous 
affections of the urinary organs, dyspepsia, hypochondriasis 
pulsations of the aorta, and further, to a marked, though a very 
slight, quotidian intermittent. Thus was my judgment of the 
true nature of the disorder formed, while it was confirmed by 
the further progress; as it afterwards disappeared almost sudden- 
ly, to be replaced by a periodical rheumatism of the deltoid 
muscle, which was succeeded by " tic douloureux" or Neural- 
gia of the face, and, in succession, by quotidian intermittent 
and other Neuralgias; that patient having in himself exhibited 
a perfect nosology of all the anomalies of chronic intermittent, 
of which this very marked and independent palpitation was one. 
And if this is one of the most perfect cases which I have met 
with to prove the cause of such palpitations, so does it afford a 
marked evidence, to be confirmed hereafter by much more, of 
the nature of all the Neuralgias, of their common connexion, 
and of their dependence on intermittent or their origin in Ma- 
laria. 



174 OBSCURE INTERMITTENTS. 

I may thus conclude the account of what I wish to call the 
Neuralgia of the heart; an account which I might have pro- 
longed, and also illustrated to a much greater extent, had I 
chosen to make of it a separate essay, instead of considering it 
a symptom of intermittent, or a local variety of one general 
disease. But if I have judged it rightly, what more might have 
been useful for its illustration will be deduced from the general 
and particular accounts of the diseases with which it is connect- 
ed, since it is here a variety and not a distinct species: while in 
an essay embracing so many things, I could not justly have suf- 
fered it to occupy more space. I shall only further remark in 
conclusion, that it will sometimes be found in patients where 
the existence of glandular visceral disease is to be suspected; a 
condition which confirms this view of its nature, while it is also 
one which, under mistaken views as to the disorder of the heart, 
is apt to mislead the practitioners into the belief of organic af- 
fections of a far different nature. Of the methods of cure I 
need not here speak, as they belong to the general character of 
the whole disease: but it will now be apparent on what princi- 
ple it is that tonic medicines act in removing palpitation, as they 
also do in many of the nervous and mistaken affections so often 
originating in the same general cause. 

It is not within my plan to inquire into the other causes which 
may produce palpitations of the heart, as there are unquestion- 
ably many; it being sufficient that by separating this particular 
kind, I shall have diminished the difficulties in which the whole 
subject is entangled: and here as elsewhere, I request distinctly 
to repeat, that while in many other cases than this, I have re- 
ferred diseases, or apparent diseases, to chronic intermittent, 1 
am not so blinded by one view of causes as not to admit all 
the others which physicians have assigned to such diseases, how- 
ever, in individual cases, I may disagree with them, by choosing 
the cause here under discussion where they may have selected 
another. Tt would indeed be to encourage and perpetuate the 
evil which has so much retarded the progress of physic, to in- 
dulge in such ravenous hypotheses, and in prejudices so unwor- 
thy of philosophy, or even of the pretensions to it. 

I must not however quit this anomaly of the intermittent, or 
this local direction of the diseases of Malaria, without pointing 
out another affection of the heart which I have observed in in- 
termittent. It is probably a rare one, and therefore the less de- 
serving of notice; since, in my own views at least, the rarer 
cases in physic are of infinitely less value than even the most 
common; while they Unfortunately possess the same attraction 
for the multitude as the history of monstrous productions and 
other accidents or mysteries, has ever done. It does however 
demand notice, because it may possibly be more common than 



OBSCURE INTERMITTENT^. 175 

iijy experience has induced me to think: and, as to know that such 
a symptom has been recorded, may not only lead to the obser- 
vation of other such cases, but afford that relief, both to the pa- 
tient and practitioner, which always follows from knowing that 
even what is mysterious is not solitary. 

If I were bold enough to give a violent term to this symptom, 
I should call it a palsy of the heart; a paralytic affection rather, 
or a diminution of energy, corresponding to that similar effect 
"which occurs in all the nerves that have been unduly excited by 
the active or painful state of Neuralgia. And, in its own sys- 
tem it presents an analogy to that singular condition of the cir- 
culation so often occurring in the chronic intermittent, when the 
pulse subsides from its former hard, contracted, and irritated 
state, so as to become slow, feeble, and languid; diminishing, as 
I have sometimes seen it do, from a hundred and twenty with, 
extreme contraction and asperity, down to fifty, as if from the 
effect of digitalis, and with correspondent languor and compres- 
sibility. 

It must in reality be plain, that under this state of the circu- 
lation, the powers of the heart are diminished; though the effect 
may not be so extensive as to be sensible to the patient, in the 
form of a feeling in the heart itself, sensible as that organ is in 
other respects: and it is therefore easy to see how a material in- 
crease of this debility may produce the more serious symptoms 
which I must now describe; a diminution in the energy of the 
heart as the prime mover of the circulation, so considerable as to 
be sensible to the patient, in the organ itself. 

I have but one case, from observation, on which I can rely, 
and as I cannot therefore generalize, I must describe it. In 
this, there was a quotidian, of a chronic nature, in which some 
of the relapses were as severe as any original disorder could 
well have been; while the obvious character of many of them 
was rather that of remittent, so long were the paroxysms and 
so imperfect the intervals. In this case, when the active state 
of the circulation was past, there succeeded a slow one, as just 
described; but so great was the loss of power in the heart, that 
it generally required a voluntary effort on the part of the pa- 
tient to maintain the pulse, while that paralytic state, if it may 
be so called, was, throughout the whole disease, proportioned 
to the severity of the paroxysm or of the fever. The suffering 
was extreme, even frightful; as the sensation was always that of 
imminent or immediate death, and of death which nothing but 
a strong exertion, both of the mind and body, could have pre- 
vented. 

Thus it was necessary for the patient to move his limbs to 
maintain the circulation; while, on remaining immoveable, 
even for an instant, the sense, with the agony, of instant death 



176 OBSCURE INTERMITTENTS, 

immediately occurred; continuing during the whole period of 
this condition of the hearty and thus often lasting for even twelve 
hours in a day. In a similar manner, this occurred on any at- 
tempt to sleep; while as the paroxysm was also attended with 
coma, the whole day was passed in a constant succession of 
struggles between the act of falling asleep and that agony of 
death which immediately aroused him to new motion. 

It was further remarkable, as proving the necessity of some 
foreign stimulus to prevent the absolute quiescence of the heart 
in this case, that when it did not stop merely by keeping the 
limbs immoveable, it immediately subsided on shutting the eyes 
to exclude the light; the pulse gradually disappearing: while on 
those trials, the patient often fell into a coma and appeared to 
be in the act of death. Nor must I omit to mention, that the 
revival of the action of the heart after this almost dormant or 
feeble state, or the restoration of the circulation to its former 
condition, was attended with great suffering, particular!}?- at those 
times when the pulse had previously almost disappeared: the 
patient describing his feelings as if currents of melted lead had 
been flowing through all the veins and arteries of the body, and 
this universal pain lasting, though gradually diminishing, till 
the pulse had regained its former strength. 

Nor was this a mere nervous sensation or a deception of the 
imagination. On desiring the patient to remain immoveable, 
the pulse, as I have just hinted, became gradually slenderer, 
till, even in a few seconds, it was reduced to the size of a thread, 
becoming finally insensible; at which moment the agony be- 
came insufferable and the patient generally started up under the 
sense of immediate death. It was supposed by the other at- 
tendant physicians, that actual death might have ensued, by a 
voluntary effort of this kind, or by a steady resolution to remain 
at rest; and considerable alarm was consequently excited by one 
or two trials that had been pushed too far: but I know not if 
this actually could have happened, from the excess of the ap- 
parent agony, though it was obviously an experiment that was 
not to be tampered with. It was remarkable at the same time, 
that when the worn-out patient did really fall asleep, the pulse, 
after subsiding during the attempts, which were often greatly 
prolonged till the very instant of slumber, gradually recovered 
its size. I have only to add respecting this state of the disease, 
that the patient was himself convinced that he could put an end 
to his existence by stopping the motion of his heart: while he 
gave proofs of his power over it, by an effort described as a vo- 
luntary command to it to cease to act; illustrating a solitary case 
already well known in the records of physic, that of Colonel 
Townshend, but in which, after some such demonstrations, 
death was the actual consequence. 






OBSCURE INTERMITTENTS. 177 

It may be useful still to add respecting this case, and particu- 
larly as this most distressing symptom is more likely to exist in 
a moderate state than in one of such excessive violence, that the 
patient continued for some years subject to relapses of the same 
fever, almost indeed to a continuous chronic state of it, but in 
a more moderate degree; and that, during the whole time, he 
never passed into the state of sleep without undergoing the same 
agonies, as of instant death, often repeated from minute to mi- 
nute, even during many hours, and frequently so threatening 
and so insufferable, as to compel him to rise, under the insupera- 
ble conviction that the attempt to sleep was to die. 

If I said that this case was a solitary one, I must presume 
that this proceeds from my own limited experience, as I can- 
not doubt that affections of the heart, more or less similar, must 
be common wherever intermittent is endemic; and also, that 
among the numerous, and often singular cases of palpitation oc- 
curring every day to practitioners, there must be many owing 
their origin to this same cause, if perhaps no two cases can ap- 
pear under the same precise aspect and character. This will be 
ascertained when practitioners shall hereafter re-examine their 
cases of this disorder under these new views: when Neuralgia 
shall become really understood as it demands, and Whenever 
also intermittent, and especially under these irregular forms and 
substitutions, shall be known to English practitioners as it ne- 
ver yet appears to have been. 

But there is a case of no uncommon occurrence which ap- 
pears to me to be connected with this last variety, or to depend 
on what I have called a paralytic tendency, or loss of energy, in 
the heart; though a mere shadow, in point of strength or effect, 
compared to the one just described. And if I might have no- 
ticed this vexatious, and reputedly nervous symptom under the 
paragraph allotted to the mental affections, it will perhaps even 
better find its place here, because I believe that the mental af- 
fection, though it is the ostensible symptom, and that of which 
the patient alone complains, is purely dependent on this very 
state of the heart, or on a loss of energy consequent upon the 
previous excited one which appertains to an intermittent pa- 
roxysm. 

The ordinary complaint of patients in this case, is an unac- 
countable sense of fear, rather than of anxiety, but sometimes 
of both united, coming on at some period of the day, but very 
generalty at night, and, above all, upon the first attempts to 
sleep. And this sense of fear is described as being sometimes 
so violent or perfect, as to produce that trembling in the hams, 
which notoriously attends this passion, although the patient is 
on his bed, and can assign or discover no cause for fear. Vet, 
as might naturally be expected, through the principle of asso- 



178 OBSCURE INTERMITTENTS. 

eiation, reasons of this nature must often make their appearance* 
since there are few who cannot find something to fear; while the 
whole train is very generally called up by the bodily sensation, 
to the infinite annoyance of even the patient who is aware of 
the cause, far more of him who is not metaphysician enough to 
discover the solution. 

Now, as far as I have examined such cases, I have found them 
to depend simply on this condition of the heart, and that they 
have occurred on the attempt to sleep, in those whose previous 
day had been occupied by a paroxysm of chronic intermittent. 
And it has been equally easy to perceive the diminution of the 
pulse, which, as in the former case, followed the attempt to sleep, 
or the act of falling into the state of slumber, and to see that 
the sense of fear was proportioned by this, and produced by it. 
I shall only add, as to this very vexatious complaint, that I have 
sometimes had reason to believe that it had become in itself a 
distinct and independent habit, though originally the attendant 
on an intermittent; or that, without any mark of a diurnal pa- 
roxysm, this paroxysm of diminished energy in the heart, with 
its accompanying fear, had become an habitual and periodical 
disease. 

As I have noticed the occasional connexion of the Neuralgia, 
or intermittent, of the heart with rheumatism, I may proceed 
to treat of that disorder in as far as it belongs to this class of 
diseases; being almost as unable to preserve any regular order in 
these anomalous modes of intermittent, as I am unwilling to ap- 
pear to prejudge a disputed question, by adopting what I should 
consider a better arrangement. If it is thus awkward to sepa- 
rate what is called the rheumatism of the face from other local 
or periodical affections of the same kind, I could not well have 
divided that from the Neuralgia with which it is connected, as 
I could not, equally, in the present state of this inquiry, have 
ventured to arrange all the affections which I have here brought 
together, under the head of Neuralgia. 

The theory of rheumatism in its various forms, is at present 
almost as obscure as that of any disease in the catalogue; and 
considering its familiarity and apparent simplicity, the fact is 
not very creditable to physicians. It is not my office here to 
attempt to rectify it; but I must endeavour, as well as I can, to 
separate those modes of this disorder which arise from intermit- 
tent or are connected with it; though, from the erroneous views 
of practitioners on this subject, and the obvious prejudices or 
ignorance under which the disease is so often described, and 
under which cases of it are misrepresented rather than repre- 
sented, it is extremely difficult to disentangle this subject. 

If the ordinary division into the acute and chronic rheuma- 
tism is a very lax one, and if additional confusion has been 



OBSCURE INTERMITTENTS. 179 

brought into this subject by classing under this general term 
other painful diseases of the joints, I trust there will be no dif- 
ficulty in showing, that, under each of these first leading heads, 
and probably also under the third distinction, ill understood as 
that is, there will be found cases that belong to intermittent, 
that are superfluous symptoms of the chronic variety, or misdi- 
rections, or anomalies; cases bearing an analogy to certain modes 
of Neuralgia, and possibly differing from it, as to the imme- 
diate cause, by the affections being seated in the numerous and 
minute ramifications of a nerve, instead of attacking a trunk or 
a leading branch; while a peculiar species of inflammation is thus 
also excited, as happens in other cases hereafter to be described 
in their proper place. 

The most simple case of all, while it is one that ought never 
to be mistaken, is that where a rheumatic pain in some particu- 
lar muscle is strictly periodical, returning and ceasing in regu- 
lar paroxysms. In such cases, the part affected may sometimes 
be exceedingly limited, occupying only a few fibres of a muscle, 
though, even then, the pain is often severe; while in others, the 
extent may be very considerable. Thus even the whole body 
may suffer under it; or rather there may be so many different 
muscles affected, in some place or other, that scarcely any move- 
ment can be made in which some one or more of the disordered 
portions is not brought into action; conveying thus, to the pa- 
tient, the feelings as of a universal rheumatism. 

If such a periodical recurrence is not sufficient to satisfy a 
practitioner respecting the true nature of such a disease, it will 
often be found attended with other symptoms explanatory of its 
cause, while these also form the proofs of the propriety of thus 
considering and arranging it. Thus it will be found to occur in 
persons who have been, at other times, affected by intermittent: 
forming, in itself, a period of relapse, and a substitute for the 
more common modes of the chronic disease. In other cases, 
the rheumatic pains will alternate with any of the other marked 
symptoms belonging to this disease; as, in the case last described 
at so much length, it does with palpitation of the heart. Or it 
may cease on the appearance of the common symptoms of in- 
termittent, or the patient may recollect that it had formerly exis- 
ted and suddenly disappeared; without apparent cause, or from 
change of place, or from the action of feeble or fantastic reme- 
dies. And hence, I may remark by the way, it is, that so many 
absurd or imaginary remedies have gained credit in rheumatism 
generally; as it is the character of intermittents thus to cease ot 
their own aceord, or to yield to trifling changes, or even, as is 
abundantly notorious, to give way to remedies acting on the 
imagination; even to charms. 

But the physician of observant habits, and who lias really stu- 



ISO OBSCURE INTERMITTENTS. 

died the diseases under review, can seldom be at a loss to disco- 
ver collateral symptoms or appearances, sufficient to enable him 
to determine the real nature of such rheumatisms; while, for 
me to detail all these, would be to repeat what I have already- 
explained so largely, and while I ought to trust, that after all 
that has here been said, not only this variety, but all the others 
which remain undeseribed, should be intelligible with little fur- 
ther explanation. One remark however I will repeat, because 
it is on a circumstance almost always overlooked, and yet one 
of the most explanatory of all that occur, not only in this case, 
but in every disorder that I have ever yet seen depending on this 
cause. It is the physiognomy of the cold stage, never absent 
at some period, however wanting the actual feeling of cold may 
be; and which has, on endless occasions, enabled me to pro- 
nounce, from the first sight of the patient, and even at a distance, 
on the nature of a disorder to which I had been summoned, with 
the assurance of its mysterious nature, and a confession of ina- 
bility to discover it, on the part of the previous medical atten- 
dants. I ought however to remark, that the power of distin- 
guishing this physiognomy, never to be mistaken for any thing 
else by him who has once known it, however slight it may be, 
belongs, if under a different sense, to what physicians call the 
tactus eruditus; while I have reason to think the circumstance 
cannot be much known, inasmuch as I have not found practi- 
tioners aware of it, except when accompanying an absolute fit 
of ague, and have often had much difficulty in convincing my 
casual associates of the fact, or in making them indeed perceive 
it when pointed out. 

I have here stated a very simple case, that of a marked peri- 
odical fit of pain, with an interval more or less perfectly free 
from it. But as I have shown that the other local or peculiar 
disorders, or anomalous forms of intermittent, may be irregular 
in various modes, just as even the pure disease often is, it is evi- 
dent that this may also be the case with the rheumatic affections, 
though I need not now repeat what those variations are, nor the 
analogies by which I explained them before. It is only for the 
reader to recollect what has already been said on this subject, to 
perceive that a rheumatism may be truly a modification of the 
intermittent, under any irregularity, and even while it may seem 
continuous; since this happens in the simplest quotidian fevers 
of this nature. 

But to detect their true character in these cases, becomes more 
difficult than to discover perhaps that of most of the other ano- 
malous intermittents; not because of any greater inherent diffi- 
culty, but on account of the prevailing prejudices respecting 
rheumatism, as if it was always an original and distinct disease: 
a difficulty which will always, and obviously, occur in the great 



OBSCURE INTERMITTENTS. 181 

majority of cases, because the great proportion, in physic, must 
always be routine practitioners, guided by symptoms, and can 
be nothing else. To such persons, it is impossible to give any 
further aid, or directions that will meet every case: observation 
and reasoning are what are required; to discard words, and rules, 
and receipts, to govern themselves by analogy and induction, 
and to learn, if that be possible, that he alone who is a philoso- 
pher will ever be a physician. 

It is plain that, under those ordinary and current views, the 
cases to which I have here been referring will generally fall un- 
der the division of chronic rheumatism, as the symptoms in ques- 
tion are the produce of a chronic disease. I do not pretend to 
enter into all the possible causes of chronic rheumatism, nor to 
conjecture what proportion of the cases which occur, be they lo- 
cal or more general, may be original diseases of a distinct nature, 
and what comparative number may belong to the cause under 
review. But it is probable that the latter cases do form a very 
large proportion of the chronic rheumatisms occurring, and that 
we are thus enabled to explain their inveteracy of duration, as 
well as their tendency to recur; properties of all the disorders 
arising from this cause: while it will also explain the action of 
the modes of cure that are successful in this disease. Hereafter, 
possibly, physicians may be induced to examine this disorder 
with more care, and by this light; and we may then perhaps ap- 
proach somewhat nearer to a true view of a disease, of which 
our ignorance has hitherto been so disgraceful. 

It is not difficult now to see, how a case of this nature might 
be mistaken for an acute rheumatism of an original and indepen- 
dent character, or considered as such; since the limits between 
the two modes of rheumatism are not, in all cases, and in the 
popular estimation at least, very well defined. A very acute or 
painful case, or one affecting many muscles, might be considered 
an acute rheumatism; and should it terminate within a limited 
time, that opinion would be confirmed; while it is plain that this 
might happen though it were a dependence of intermittent, since 
it occurs in the simple intermittent itself. 

The more serious question remains; whether that which is 
esteemed acute rheumatism, a disorder too well defined and too 
familiar to require description here, may be a mode of intermit- 
tent. I do not mean to suggest at present, that every acute rheu- 
matism is a disorder belonging to this class of diseases, or that, 
as in the chronic variety, there are not cases which are indepen- 
dent disorders, or affections generically different, although it 
seems to me, that even this is a question far from decided the 
other way. The question at present is, whether there are not 
acute rheumatisms of the most regular form, which arc truly 
modes of the quotidian intermittent, or of the remittent, possi- 



182 OBSCURE INTERMITTENTS. 

bly, originating in the same causes: and if it shall be decided 
that this is the fact, and that there is also an acute rheumatism 
generically different, then we shall probably be able to explain 
the causes of the contests so long maintained respecting the use 
of bark in this disease. 

The facts which would seem to prove this opinion, are chiefly 
these. There is a periodical exacerbation, if there is not always 
an absolute remission of the pains; and the duration of the dis- 
ease is very analogous to that of a remittent, or of one period 
of an intermittent. The causes correspond, if they are not 
identical, while the remedy is often the same; since, after all 
that has been disputed, there is no doubt that many cases are 
cured by bark, and that blood-letting is not only often ineffec- 
tual, but pernicious; its action altogether, being, in fact, very si- 
milar to that which it exerts on remitting and severe intermit- 
ting fevers. 

Thus while, in acute rheumatism, the misapplication or abuse 
of blood-letting often produces the chronic disease, so does a 
similar practice frequently induce the chronic state of intermit- 
tent, or convert an acute and terminable case into a durable one. 
It is not impossible also that the termination of the pains of acute 
rheumatism, succeeded by affection of the brain, and so often 
producing death, may be an analogy to what happens in other 
cases of intermittent diseases, where one local affection is ex- 
changed for another, or disappears to be replaced by an augmen- 
tation of the general fever: while I can further easily understand, 
that the misapplication or the injudicious excess of blood-letting 
in such a case, may absolutely produce that comatose state which 
sometimes occurs in this disorder, and which is so generally 
considered a transference of the inflammation; since this is the 
very apoplectic state, if I mistake not, which is produced in the 
same manner in remittent and intermittent fevers. With what 
propriety therefore blood-letting is resorted to in the cases of 
this nature, will be abundantly palpable, should this view be but 
even sometimes correct. 

Ji priori, there seems no reason against this view, whether 
it shall be borne out by a stricter and fuller examination of evi- 
dence or not. If an intermittent of a chronic and slender cha- 
racter can produce, or find its substitute in, a rheumatism of simi- 
lar qualities, so it is not unreasonable to suppose that the locali- 
zation, in a corresponding manner, of a severe intermittent or 
remittent, may produce the acute disease of this nature. -And 
there is abundant analogy besides, in support of the same views, 
from the various and truly acute inflammations, as far as rheu- 
matism itself is such, which occur so often in remittents and 
intermittents, in certain seasons or epidemics especially, and of 
which, histories abound in authors, though my plan excluded 



OBSCURE INTERMITTENTS. 1S3 

them. Such are pleuritic and catarrhal affections, anginse, he- 
patitis, inflammatory affections of the stomach and bowels and 
of the spleen, as well as, further, of the brain, and even more; 
and such is that severe though peculiar ophthalmia which I have 
been compelled to arrange in another place; while, were more 
decided facts wanting, it is fully shown by many foreign wri- 
ters, that this very disease, an acute rheumatism, is one of the 
symptoms of such fevers, since it is from this very variety, ap- 
parently, that the Arthritica of Sauvages has been formed. Let 
the fever be obscure or irregular, or let it be absorbed by the at- 
tention to the local disease, or let the physician be inattentive, 
or have predetermined his theory, and there will then cease to 
be much difficulty as to this question, or as to the facility with 
which the error of supposing the acute rheumatism a primary 
and independent disorder may be committed; though the extent 
of its bearing and value must be reserved for a much more am- 
ple investigation: yet for one that must be conducted by persons 
willing to believe that they are still ignorant and have all to 
learn. 

And let me add while on this subject, that when Morton as- 
serts that the pains in acute rheumatism were often removed by 
emetics, when he describes distinct tertian as well as quotidian 
rheumatisms cured by bark and opium, and when he speaks of 
the "Febris intermittens rheumatismum simulans," he offers a 
strong testimony, with respect at least to the frequent existence 
of a rheumatism of this nature; as, I have little doubt, does 
Haygarth's well-known report. As to the rheumatism of the 
joints, as it is called, a disorder which, like the former, is, as far 
as it is intermittent, much confused by the ancient authors, in 
consequence of a vague use of the term "arthritica," we have 
also the modern tertimony of Wardrop respecting the utility of 
bark as a remedy. But I will not venture further on this con- 
jectural ground: it is sufficient if I have thus pointed out an im- 
portant field of inquiry; while the determination must finally 
rest on evidence, but on evidence to be sought and weighed in 
a manner which we could wish to be much more common in 
physic than it is. 

If I have said all that appears necessary in a general view 
respecting the connexion of rheumatism and intermittent, it is 
still necessary to point out varieties, depending on the parts 
which happen to be the seat of the pain. It is not because the 
general principles do not apply equally to all, that this is expe- 
dient; but from the experience that these have no influence with 
the mass of practitioners, whenever any thing remarkable in 
the place of the disorder, or the obvious symptoms, lead those 
who have no other guides than words and symptoms, to refer 
them to some familiar disease, however different the real nature 



1S4 OBSCURE INTERMITTENTS. 

of that may be. If, in such hands, every acute pain in the chest 
is a pleurisy, it is easy to see what the consequences may be; 
and as this is, as far as I have seen, one of the most common of 
all the errors on this head, I shall bestow the first place on it. 

To say that rheumatism of the intercostal muscles is perpetu- 
ally mistaken for pleurisy, in the hands of negligent practition- 
ers, is to state a fact known to every observing physician; and 
it must equally be known to many, that the practice of blood- 
letting, always resorted to under this mistaken view, is very 
often to perpetuate or render chronic what, under correct treat- 
ment, might have subsided in a short time. If I have seen con- 
stitutions utterly ruined by a perseverance in this wrong prac- 
tice, if I have seen patients condemned to believe themselves 
labouring under consumption in these cases, with all the expen- 
sive and vexatious consequences that follow such an error, there 
are doubtless many physicians to whom the same facts have oc- 
curred. And though it is out of the bounds of the present 
inquiry, I cannot proceed with the subject, without observing, 
that even in decided cases of pulmonary inflammation, it is not 
uncommon for patients, and particularly after much blood-let- 
ting, to be seized with acute pains of the intercostal muscles, 
interfering with respiration; and which, in careless hands, very 
often, perhaps very generally, lead to the repetition of this reme- 
dy, when, in reality, it is not only useless, but has become high- 
ly pernicious. To distinguish these pains from internal inflam- 
mation, is most important: and it is often to be done easily by 
merely pressing hard on the painful point, which, it is well 
known, removes or suspends for a time a rheumatic pain. 

Having stated this common fact, I am not, of course, about to 
maintain that every rheumatism of the intercostal muscles be- 
longs to the intermittent; but I have seen many such cases where 
there could be no question on that subject, and where the most 
serious evils have followed the erroneous view and the wrong 
practice. If I state one case, as briefly as I can, in illustration, 
it is not only because it offers a good specimen of what is very 
common, but because there are facts in it which will illustrate 
this class of cases better than a general statement could do. 

The patient was a young man in the higher rank of life, and 
the pain in the side was termed pleurisy, though no cough was 
present, and very little fever; so little, that not even confinement 
to bed was necessary. Blood-letting was resorted to, very ac- 
tively, and was followed by increase of the pains; and, not to 
prolong a tedious history, these pains continued or returned oc- 
casionally, during nearly a whole year, while, during all that 
time, this remedy was repeated, often, many times in a week. If 
it was plain that this, by merely negative reasoning, must have 
been a rheumatic disorder, there was even much plainer evidence. 






OBSCURE INTERMITTENTS. 185 

in the periodical returns of the pain, after some weeks, that it 
was also the intermitting disease; while the physiognomy and 
appearance marked, once in every day, a decided cold stage, 
Still further, after about five months, there came on a pain in 
the shin-bone of one leg, regularly periodical, and lasting five 
hours; during which the rheumatic pains among the ribs dimi- 
nished or ceased, yet without leading the physicians to a correct 
judgment of this case, as it ought to have done; being a true 
Neuralgia, interchanging partially with the original intermitting 
rheumatism. And if, in the present stage of this essay, the ex- 
planation now given may appear unfounded or unintelligible, 
there will be abundant proof, in the following volume, that this 
view is a just one, and that analogous cases also are very com- 
mon: this very class of facts, in reality, constituting one of the 
essential and characteristic circumstances of all these diseases. 
So far, however, were the attendants from even conjecturing the 
cause or nature of any part or form of this merely varying, but 
identical disorder, that, although there was, at this time, not on- 
ly a regular cold stage, but the comatose state of intermittent, 
lasting daily for some hours, the disease was then reported as a 
wonderful and mysterious case; until at length it was actually 
proposed to make an incision through the periosteum, into the 
pained part, on some theory of a disease in the bone; though 
nothing was to be felt. This, I have in reality known to be 
done, in a parallel case; while the patient here fortunately esca- 
ped this evil, by the sudden cessation of the pain; very possi- 
bly the consequence of the alarm, which so often removes Neu- 
ralgia. 

Not to proceed further as to this case, I shall only add, that 
as has happened in every similar instance of mistreatment that 
I have seen in these disorders, the patient's health was so much 
injured that he did not recover his strength during many years, 
never regaining his colour; and that while the chronic pains <^n 
the ribs recurred repeatedly, to be always treated in the same 
manner, there supervened spasms of all the muscles, with affec- 
tions of the intellect, after one period of very severe treatment 
of this nature; and, at length, a marked period ,of the disease so 
long present under other modes, namely, a regular quotidian, 
which lasted nearly a year, and which, for aught that I know, 
remains uncured. If I must apologize for the length of this 
case, it will be not without its uses, as a very complete specimen 
of neglected evidence, of error and maltreatment, and of the 
consequences of this last; which are those that for ever follow 
under such erroneous practice, if in different degrees. 

If the case that I have thus described was a quotidian, there 
is no evidence wanting respecting the existence of tertians of 
the same nature: though it is not from them, but from an acute 

24 



1S6 OBSCURE INTERMITTENS. 



disease, probably also different, that Sauvages has derived h 
variety the Tertiana pleuritica: and I need scarcely remark over 
again, that any one of all the anomalies that I have described, 
or shall describe, may also be found under the quartan type, or 
under those complicated forms which I have not chosen to dwell 
on. It is plain that, in the latter cases, the chance of error, on 
the part of a careless or uninformed practitioner, is even greater; 
as the want of a very simple and fixed period, will deprive such 
a person of the most obvious criterion of the disease. 

And I ought to make another remark here, though it has been 
occasionally noticed for other purposes, elsewhere; since it not 
only concerns these cases of rheumatism, when chronic, but ma- 
ny more of the simulating diseases of this connexion or genus; 
and because it is from ignorance of this common fact, or from 
inattention to it, that the characters of these disorders are, part- 
ly, mistaken, and, further, disputed or denied; or that the diffi- 
culty arises, of convincing persons who have not bestowed at- 
tention on this subject, and are unaware of the facts which con- 
stitute the very basis of this work, that such diseases do really 
belong to intermittent, and are but modifications of it; requiring 
the same treatment, and, in truth, scarcely ever to be removed 
in any other manner. This is, that in all ancient and inveterate 
cases of even simple intermittent, it is common for the disorder 
to become so very irregular, that nothing but great experience 
of such cases, or an accurate and philosophical knowledge of 
the disease as I have attempted to describe it, can recognise it, 
under that form, or even perhaps believe that it is the intermit- 
tent fever. Not only does it vary in type, in every mode, or 
cease to have any type at all, but it may recur in a single at- 
tack, or in two, or in any number, separated at irregular inter- 
vals, or, on the contrary, become absolutely continuous, or, in 
short, appear under modes of variety and confusion which are 
best left to the imagination to conceive. Thus also may it put 
on more forms than one: or what is a simple fever on one day, 
or through one week or month, may be an inflammatory affec- 
tion, or a merely painful one, on some other occasion; such dis- 
orders even interchanging with Neuralgia, as 1 shall more fully 
show hereafter. Thus it is easy to see how, if the case should 
be a rheumatism, these irregularities, united to the common theo- 
ry respecting this disorder, would confound the judgment of the 
practitioner, or render it impossible to convince him that a dis- 
ease so irregular could possibly belong to an intermittent type. 

As to the true pleuritic intermittent, an acute disease under 
a severe fever, I have no experience: and I may therefore refer 
to the nosologist above named and to foreign authors, for what 
has been fully described; whether I am convinced or not, that, 
in these cases, the lungs being unaffected at the same time, the 



us 
r er 



OBSCURE INTERMITTENTS. 187 

local disorder has been aught else than a severe rheumatism of 
the same parts. Yet with regard to a pleurisy of a perfect cha- 
racter, and possessing every symptom of the ordinary disease of 
this nature, but depending on intermittent, and often also, itself 
periodical and intermitting, in tertian as well as quotidian forms, 
there ought to be no doubt, since Morton says that he had seen 
a hundred cases, and that, like the fever itself, they were cured 
by bark, and by nothing else. It might possibly be supposed 
that such cases were sometimes the mere rheumatism of the in- 
tercostal muscles which I have described; but Morton is too 
good an observer to permit us to draw this conclusion univer- 
sally, while there is no reason why an inflammation of the pleura 
itself, or even of the lungs, of this peculiar character, should 
not occur, as well as that of the eye or of the stomach and 
bowels. 

Of other rheumatisms affecting particular muscles, possessing 
the character of intermittent, and being modes of that disease, I 
think it unnecessary to point out particularly any other than 
that of the loins; as this also is one of those which, having a 
name of its own, the lumbago, is very generally misapprehend- 
ed, or perhaps almost never referred to the disease of which it 
is, sometimes at least, a modification. There is abundant evi- 
dence of its being often what I have now stated it to be, though, 
how often, I cannot here pretend to say; and if the evidences 
are similar to those already enumerated, I can add one very 
pointed case, where a disorder of this kind, particularly well 
marked, and long treated as a common lumbago, was suddenly 
and spontaneously removed, and immediately succeeded by the 
common Neuralgia of the face. There is also, if my reading 
has been duly remembered, a similar case recorded by Dr. Pear- 
son; and I prefer any one's testimony to my own, when I can 
find such, because I am the more sure that there is no bias, or 
at least, that it will not be suspected: as it very naturally must, 
when the promulgator and supporter of the theory is also the ob- 
server of the evidence. 

I might now consider those rheumatic pains, as they are vul- 
garly considered, which are found occasionally in places not 
muscular, and which may occur in almost any part of the body. 
But 1,he term rheumatism is assuredly here misapplied, under 
any view: while there are many reasons for associating many 
of these disorders at least, with the Neuralgia in its more com- 
mon form, and thus deferring them to the latter part of this es- 
say. The rheumatism of the face and of the head, as they are 
called, belong to this division; and as it seems much more con- 
venient to place these with the common Neuralgia, it would 
produce even more confusion than I have now made, very un- 
willingly, if I were to describe here the affections which are pre- 



188 OBSCURE INTEHMITTENTS, 

eisely similar in character, differing only in parts which they 
occupy. Hence some of the varieties apparently, which have 
been ranked under the term Arthritica, and which seem to me 
to belong to this division, will fall to be considered hereafter. 
Thus also will the headachs be much better treated of in the 
same place; on account of their obvious connexion with the most 
definite Neuralgia of the head. 

But as to a true arthritic rheumatism or affection of the joints, 
I have great cause to regret, that since I have thus far extended 
my views of the local actions of intermittent, I have had no op- 
portunities of treating or seeing that inveterate disease of the 
joints, of this nature, which is so well known, and which is so 
much more common in the female sex than the male. I cannot 
therefore discuss it, nor must I even dare to suppose that it may 
be a disease belonging to this place: but if what I recently quoted 
from Wardrop as to the value of bark in it, shall prove gene- 
rally or extensively true, it will present at least a strong ground 
for suspicion that it really does belong to the anomalous inter- 
mittents. 

I must therefore pass to some other diseases of a local or pe- 
culiar nature, connected with intermittent as symptoms or mo- 
difications, however rare a few of them are, and however ob- 
scure the connexion may sometimes be; while among them also, 
there are some that might perhaps have been most properly ranked 
with the Neuralgia. 

Of these, diarrhea at least is perhaps best placed here; though 
it might indeed have been more correctly arranged with those 
cases where secretions are especially affected, and therefore un- 
der the head of Neuralgia. But there is always a difficulty of 
choice, here, in these arrangements; on account of the different 
relations of any one assumed disorder, to a general, or to a lo- 
cal affection, or to fever or Neuralgia, as its leading genus or 
division; independently of its relations to a continuous or remit- 
ting fever, or to an intermitting one: while all this inconvenience 
has arisen, fundamentally, from the vexatious necessity of fol- 
lowing ancient prejudices and ill-combined systems, in treating 
of what belongs in reality to an arrangement as radically dis- 
tinct as it is essentially new. And if I need not here repeat 
what I took occasion formerly to say of dysentery and diarrhea, 
I ought however to premise, that as far as diarrhea depending 
on the action of Malaria, or on the remittent fever, is a conti- 
nuous and acute disease, whether it should be accompanied by a 
marked fever or not, I need not here notice it again; my object 
in this place being to point out a chronic diarrhea rather than an 
acute one, and a periodical rather than a continuous disorder; 
and chiefly for the same reasons, the mistakes to which it gives 
rise; though partly also that I might bring under one general 



0ESCURE INTERMITTENTS, 189 

view for the sake of mutual illustration, and for the purpose of 
establishing the general theory, as many simulations of inter- 
mittent as I could collect. It is plain however that there is no 
essential distinction between this diarrhea and the more regular 
one formerly noticed: though if remittent and intermittent are 
to be separated, there are the same reasons why all the simula- 
tions under intermittent should be separated from those under 
remittent fever. If these disarrangements are an evil, the radi- 
cal evil lies there; and, consequently, there is at present no 
choice: while perhaps the good may really outweigh the incon- 
venience, on account of the advantages arising from it in the 
practice as to those disorders. 

The diarrhea which I purposed chiefly to point out here, is 
one that belongs to decided intermittent, occurring in the chro- 
nic tertian as well as the quotidian,- and, for aught that I know, 
in many other types. If I cannot at present find satisfactory 
cases in authors, and if it is not noticed in Sauvages' useful 
work, I have seen it occur most distinctly under both the types 
that I have named, as a substitute for the common fit of ague; 
while, in one instance, which might therefore claim the name of 
double tertian, the one day was regularly a common paroxysm, 
and the other a diarrhea, so punctual in the attack as never to 
fail at the hour of eleven in the morning. 

So many causes may produce a chronic diarrhea, and the or- 
dinary habits of the body, obedient as it is, in many other cases 
than ague, to diurnal periods, may so render such a common di- 
arrhea periodical, that I am afraid to lay much stress on the 
cases of this nature that have come under my notice, or to refer 
them to the variety under consideration; feeling that natural fear 
of being suspected of undue bias to a system and a cause, for 
which the whole of the views laid down in this essay will ap- 
pear to have given so much ground. Yet I think that physi- 
cians are bound to consider such a disorder as possible, and as 
possibly much more frequent than I can prove it to be from my 
own observations; while I could easily enumerate many more 
cases of periodical diarrheas, and, what is essential, occurring 
in persons who had, at other periods, been affected with chronic 
intermittents and Neuralgias, where this solution has appeared 
the probable one. And in every case of this nature on which I 
would lay any stress, the absolute necessity of quelling the dis- 
ease by the ordinary remedies, and the suddenness with which 
it spontaneously disappeared on a change of place or habits, 
confirmed this view; since it is thus that all the modes of chro- 
nic intermittent behave under similar circumstances. To pass 
now to a very different disorder. 

I need not minutely describe a species of cough which some- 
times occurs: which is not of pertussis, does not arise from af- 



190 OBSCURE INTERMITTENTS. 

factions of the liver, and is not attended with any expectoration? 
nor apparently with any affection of the bronchial membrane or 
the lungs. Its common designation is, a spasmodic or a ner- 
vous cough; and, numerically, it is more common in women 
than in men; while its leading character is, to supervene in vio- 
lent fits, commonly with long intervals of entire freedom from 
even the suspicion of disease. What it may be in all cases, it 
is not here my business to inquire; but that it is an intermittent 
disease, and sometimes of periods extremely regular, to be 
cured by the remedies of intermittent fever, I have often expe- 
rienced. 

I know not that this anomaly is ever of the tertian type, but 
have seen it under the quotidian, occurring at regular periods, 
and lasting a definite time; while in some of the cases, it was 
held to be a very mysterious disorder, though in others, called 
by the vague term a spasmodic cough, and treated, to no pur- 
pose, by the common antispasmodics. That, in one instance, 
after a long duration, and under such extreme severity in the 
cough, as to have produced repeated abortions, it was almost in- 
stantaneously cured by the remedies of intermittent, was to me 
a further proof that I had judged rightly of the nature of the 
disease. In another case, the quotidian regularity was perfect 
and definite; as the cough returned regularly at three o'clock in 
the morning, with extreme severity, and lasted precisely half 
an hour: while this patient, after many weeks of the disorder, 
was cured within three days by means of bark. It will be for 
practical physicians to review their cases of spasmodic cough, 
and to inquire whether some of them do not truly belong to this 
disorder. 

There is something singularly periodical in the attacks of a 
catarrh which often comes on in summer, and, as it would ap- 
pear, most commonly from exposure, not simply to heat it 
would generally seem, but to heat where vegetation is present. 
This well-known disorder is produced by hot-houses or green- 
houses: and, in the public estimation, it is particularly caused by 
hay-fields. Hence the term Hay fever, lately become fashiona- 
ble. I do not mean to say that because this is a periodical ca- 
tarrh it must be a mode of intermittent, or that it is a misdi- 
rected case analogous to all the former. But having a quoti- 
dian period, and being the produce apparently of heat and ve- 
getation, it at least presents features of analogy which renders 
it worthy of being here noticed, and also of being more mi- 
nutely studied; as far at least as we can investigate a disorder 
generally too trifling to attract much notice. But, if the me- 
thod of cure is not that which removes intermittents, and offers 
therefore no confirmation of such a theory, I may remark, as a 
matter of utility, that it is aggravated by the remedies which 



OBSCURE INTERMITTENTS. 191 






aggravate intermittents, namely, by blood-letting and evacuants, 
though, unfortunately for the patients, this is a common prac- 
tice. 

I have no experience in cases of such extreme severity as 
that described by Dr. Bostock, and must not therefore pretend 
to entertain any opinions; it must be for those who know it in 
such forms, to inquire further into its nature; nor could the in- 
quiry be in better hands than those of him who has suffered 
from it. But I must add, that while I have never had any op- 
portunity of treating it as if it was an intermittent, I have ob- 
served that opium, and stimulants in general, including wine, 
formed the most successful practice; while the slighter cases, still 
abundantly teasing, and conspicuously so to clerks in various of- 
fices in summer, among whom it seems to be produced by the 
heated air of their confined rooms, appeared to be most readily 
managed by resorting to the use of snuff, under which the ha- 
bit also of suffering from this singular disease at length disap- 
peared. 

On other occasions, I have here shown that many of the lo- 
cal disorders thus described as belonging to the chronic marsh 
fevers, occur also in an acute form, in those of a severer cha- 
racter; the one occurrence illustrating the other, and, as appears 
a fair conclusion to draw, confirming the probability in cases 
that might otherwise be doubtful. How far therefore the pos- 
sibility of such a catarrh as the one I have here described, if 
not of the individual disorder in question, is confirmed by the 
frequent fact of a catarrh united to severe marsh fever, remittent 
or intermittent, an occurrence whence Sauvages has derived his 
Catarrhalis, I must leave to the judgment of the reader. Yet I 
may also notice here, what is more particularly mentioned un- 
der the head of Neuralgia, that in cases of hemicrania, itself an 
intermittent disease, and very often a mode of common chro- 
nic intermittent, or a substitute for the ordinary form, it is not 
at all unusual to find a catarrh as rigidly periodical; sometimes 
accompanying it, at others a substitute for the headach, and oc- 
cupying one nostril only, with not unfrequently also one eye. 
I need not say that in the summer catarrh above mentioned, the 
eyes are very frequently affected, and, in the severer cases, to a 
very high degree. 

It might not perhaps *be easily credited by those who have 
been little accustomed to watch the general practice for the pur- 
pose of supplying the defects of their own experience by that 
of others, still less by those who have never studied the ob- 
scurer forms of intermittent, that this disease has been mistaken 
for phthisis. Yet have many such cases occurred in my own 
limited experience; while the proof has been rendered complete, 
not merely by a narrow investigation of the symptoms, but by 



192 OBSCURE INTERMITTENTS. 

the success of the remedies: having thus cured, more than once, 
such a reputed inveterate phthisis, and even of long standing, 
by a few ounces of bark or grains of arsenic. And thus have I 
seen cases of this nature cured, often almost suddenly, by change 
of air, as I have seen a journey into Italy recommended on that 
ground: while, doubtless, successful as this remedy is often like- 
ly to be, a reputed cure of consumption has been more than 
once effected under this error. 

I know not whether I ought to consider these as cases of ac- 
tual simulation on the part of the disease, or of ignorance and 
inattention on that of the practitioner: others must decide this 
point as is most flattering to themselves, should such a case have 
been their own. How far the symptoms are thus entitled to 
deceive any one, may thus be judged. The periodical fever is 
misinterpreted into hectic; and the debility, the thirst, the pale- 
ness and shrinking of the skin, possibly that of the vessels of 
the eye, the emaciation, not uncommon in such chronic fever, 
and more which I need not detail, have thus combined in de- 
ceiving those who forget to distinguish between a hectic and an 
intermittent paroxysm, and who do not recognise the very marked 
physiognomy of intermittent: while, should occasional pains of 
the intercostal muscles be present, an occurrence, as is here 
shown, often so striking as to lead to a belief in pleurisy, the 
error becomes complete. It is even more inveterate should 
there be cough, as may happen from visceral affections, or an 
occasional catarrh, which may occur to any one, or that catar- 
rhal disease which seems to be one of the simulations of this 
protean fever, or lastly that cough of habit so common in per- 
sons who indulge in this act, and not very uncommonly pro- 
duced by the smoke of London in many irritable individuals. 
I describe here the various causes of deception which I have 
witnessed; while I ought also to add, that in young females, 
chlorotic appearances, and disorders which I need not specify, 
frequent attendants on this chronic fever, receive the same in- 
terpretation. If, under such circumstances, I have more than 
once put a stop to a sea voyage or a journey to Nice, removing 
also the most unfounded and serious alarms, promising the cure 
which was sometimes speedily effected, or, even when failing 
in this, as we so often fail in chronic intermittents, relieving 
the patient's mind, I can give no other rules for the guidance of 
others in such cases, than to recollect that there are such dis- 
eases as I have here described, and to exert their observation in 
discriminating them. 

There is a disease called nervous atrophy which it would be 
very desirable that physicians should describe or define some- 
what better than has yet been done. That it arises at times from 
intense and durable grief, seems ascertained, as perhaps also from 






OBSCURE INTERMITTENS. 193 

sudden and severe disappointment: the disorder, in the latter 
case, producing its obvious effects in an analogous sudden man- 
ner, while more gradually in the former. That the disease of 
the mesenteric glands is thus sometimes misnamed, is also well 
known: but, beyond that, what is its nature and what its 
causes, if there be other causes, is a question yet to be solved. 

Like others, I also have seen cases arising from the mental 
causes just named: but of all the reputed ones which have fallen 
in my way, whether in the practice of others or in my own, 
three-fourths have been instances of chronic remittent or inter- 
mittent, and, as far as I could ascertain, without any demon- 
strable mark of visceral affections, though where the spleen is 
the organ affected, it is far from easy to be satisfied of this fact. 
And from the hands in which I have seen such cases misappre- 
hended, persons of the highest repute in physic, I have little 
doubt that it is a not unfrequent error, to add to the number of 
daily practical errors on this subject. Did delicacy allow me 
to name some of these cases, I doubt not that the reader would 
require little other evidence as to this oversight. 

As in the case of simulated phthisis, I ought rather to call 
these cases of error on the part of the physician, than that of 
fair simulation on that of the disease; yet the facts as thus stated 
will not be less useful in practice. On one of them I must 
however observe, very pointedly, that the paroxysm of quoti- 
dian intermittent was most perfectly marked, but that its period 
being in the night, the attendant physician, of the highest re- 
pute, and I may add, deservedly so, and with the advantage also 
of being a friend of the patient, had not perceived it after a 
three weeks' attendance; the nocturnal occurrence of paroxysms 
being a source of error which I have had occasion already to 
m point out in this essay. I need scarcely add, that this patient 
was cured, and very speedily, by a change of system; since it 
was a fever of the most regular character and of no very long 
duration. In some others, the cure has been effected by change 
of air, and in two instances almost instantaneously ; though I had, 
even then, some difficulty in convincing my predecessor of the 
real nature of the disease. How it may be distinguished, it 
would be mere repetition to say: but it is easy to see how the 
paleness, emaciation, want of appetite, and so forth, which be- 
long to this fever in so many cases, might be thus misinterpreted 
by a hasty or careless observer; while, in this case as in so 
many others, the term nervous atrophy is unfortunately at hand, 
presenting itself to the imagination of the physician, like so 
much more of the eternally mischievous vocabulary of physic, 
and thus quieting the conscience and saving the necessity of fur- 
ther thought or investigation. To conclude, I am satisfied, 
from sufficient observation, that what I have here said is not 

25 



194 OBSCURE INTERMITTENS. 

superfluous, though Willis has pointed out the atrophy which 
follows long-continued fevers; since these are cases of a decided 
nature, respecting which no error ought to happen; though even 
here, it is not improbable that the disorder was, sometimes at 
least, that very obscure and chronic state of the original disease 
itself which I have described; well known to this observer, if 
too often neglected by his successors. 

The last of the local anomalies of intermittent which I pur- 
pose to nofffce, may perhaps be placed under the quotidiana 
stranguriosa, though this might perhaps, even more justly than 
the preceding, have been referred to the Neuralgia?. It may not 
possibly be very common; but having seen three marked in- 
stances of it within a very short time, and in a very limited 
practice, I shall not be surprised if it is not a very uncommon 
mode, though it will, like all the other local diseases of this 
class, never appear so until physicians shall become more accu- 
rate observers of causes, and pay more attention to that class of 
disorders which I have here been attempting to illustrate. 

In each case, it was easy to determine that the disorder was 
truly a modification of intermittent, though there were differ- 
ences. In two, it was the substitute for the more common re- 
lapse; while the accompanying and characteristic symptoms 
were those which I have already described, and while one of 
the patients had been subject to different returns of it. In the 
other, there had been no chronic disease before; but the first at- 
tack took place in the bladder and in a very young person; 
while the characteristic circumstances were found in the exact 
quotidian and temporary nature of the returns; that patient 
having also been exposed to a marked Malaria. In all, 1 ought 
to add, its nature had been at first mistaken, and, in all, it was 
cured by altering the treatment; the last, in a very pointed man- 
ner, by a few doses of kina. If I have ranked these cases un- 
der the quotidiana stranguriosa, it is to avoid multiplying dis- 
tinctions; but in one of them the disorder was rather analogous 
to that irritability of the bladder which attends what is called 
its catarrh, while the other consisted in a dull pain, with a sense, 
as of occasional spasmodic contractions; the urine in both cases 
remaining unaffected. In the third, it appeared to be merely a 
rigid spasm of the neck of the bladder, producing complete sup- 
pression of urine as long as the quotidian paroxysm lasted, and 
demanding the aid of the catheter. 

I shall now terminate this enumeration of the anomalies 
which I have collected from my own practice, as arising from 
intermittent fever or its causes; or of the modifications, if this 
is a better term, under which that disorder appears. I have 
already stated the impropriety of separating some of them from 
Neuralgia, and the comparative inconvenience of thus distin- 



OBSCURE INTERMITTENTS. 195 

guishing even those that are not of the rigidly local character 
which would justify this precise term; while I have stated also 
the reasons of expediency, the unwillingness to shock common 
prejudices, which lias led me to adopt a division that I cannot 
approve. Hereafter, I may possibly attempt to suggest some 
better arrangement. 

It will nevertheless not be useless in the present stage of this 
description, to give a general, though an imperfect list of the 
disorders which will hereafter be described, and which are so 
intimately connected with those which have now passed under 
review, that the separation is often as inconvenient as it is arbi- 
trary. It will be convenient therefore, even now, that the reader 
should foresee what is intended respecting these ill-understood 
diseases. 

They consist then of local headachs, such as clavus and hemi- 
crania, and also of periodical ones; all consecutively associated 
with those already described under remittent and intermittent 
fevers, but, as it happens, distinguished in physic as indepen- 
dent diseases, and hence compulsorily separated here. To these, 
as bearing a near and similar affinity, I may here add toothach, 
under a variety of appearances, and the proper Neuralgia of the 
face, or tic douloureux. In other parts of the body, there are 
Neuralgias of various characters, including sciatica, and appa- 
rently lumbago, together with the frequent consequences of all 
those paralytic affections; intimately connected with those al- 
ready described, and with the apoplexy and lethargy fully dis- 
cussed under the marsh fevers. Of inflammatory affections, the 
ophthalmia alone has claimed a distinct place, conformably to 
established custom; the analogous disorders having already been 
examined as far as it was necessary to refine respecting them. 

This general idea may suffice; and with what has passed, it will 
convey a broad view of the diseases or symptoms arising either 
from marsh fevers or from the causes by which those are pro- 
duced: sometimes palpably connected with a diurnal or periodi- 
cal fever, at others less visibly so; whether from the actually 
inconspicuous nature of the febrile symptoms, or from the great 
conspicuity of the particular disorder or local effect, or from the 
errors and prejudices, or want of discrimination, which have 
erected these into distinct and independent diseases, thus tending 
to impede a correct observation. 

The whole of this list, as it has passed and is to come, is, I 
am aware, a startling one, both from the number and the nature 
of the diseases. It is easy to foresee the criticisms to which it 
will give rise: no less than to foretel the remarks which will be 
made on the former attempt to prove a more general existence 
and a wider diffusion of Malaria than has commonly been sup- 
posed. I shall be accused of extravagant generalization, and of 



196 OBSCURE INTERMITTENTS. 






that absorbing prejudice as to a favoured hypothesis in which 
physic abounds but too notoriously. But every man knows 
whether he is attempting to support an hypothesis, or to make 
an induction from facts; and I may therefore at least say that my 
belief is a conscientious one; because I have spared no efforts in 
sifting and balancing evidence, and because that appears to me 
to be evidence; while the conclusions have been drawn by the 
rules which I have been accustomed to apply to the accurate 
sciences. 

Under such an impression, I should even consider it a crime 
against humanity not to state my experience; though, if the 
proofs which I have produced and shall produce do not lead to 
the conviction of others, this is no cause for surprise; because, 
in all similar cases, the same difficulties have been experienced, 
while time effects what argument and evidence never yet did, 
and while the most energetic opponents often become the most 
forward teachers of what they commenced by denying. 

But, even including what remains to be described under Neu- 
ralgia with all that has preceded, and adding also what I am 
about to borrow from foreign authors, I do not by any means 
think that I have succeeded in making a complete catalogue of 
this class of disorders, or that I have done for this subject what 
some future writer may be enabled to effect, and which, who- 
ever may attempt it, will now find a comparatively easy task; 
inasmuch as the more difficult part is accomplished, and the 
mode of proceeding marked out. A more laborious research 
into cases and records than I have had the inclination to make 
or the means of making, may perhaps add much illustration to 
what I have here generalized as well as I could, and may also 
add some new modes, or diseases, which I do not yet know as 
claiming to be ranked with my own list. Thus also will a great- 
er range and variety of practice than have fallen to my share, 
with greater opportunities of observation, add, doubtless, much 
useful illustration; while they may confirm the present views 
by new evidence, and further, may perhaps add to the catalogue 
itself, by tracing symptoms or groups of symptoms hitherto li- 
mited to some other well-known disease, to a cause which seems 
to mimic in its effects so many independent disorders, and, pos- 
sibly also, to be the sole cause of some that have hitherto been 
supposed of a widely distinct nature. But I must proceed to 
state what I have selected as of value in the further illustration 
of this subject, remarking only, that this illustration is meant to 
apply equally to the anomalous cases quoted under remittent, 
which I have so unwillingly separated from the present. 

I have, more than once, stated some of my reasons for pre- 
serving my own cases and the observations from which I have 
derived what I must often consider new views of intermittent, 



OBSCURE INTERMITTENTS. 197 

and of this subject in general, distinct from the authorities which 
I have quoted in their support; the chief of these being the great- 
er weight which ought to follow from original and independent 
observation, and the consequent generalization of uninfluenced 
opinions and an unbiassed system. In addition to these, I shall 
only observe here, that as I should certainly no more have de- 
rived this generalization from the perusal of recorded cases than 
others have done before me, so, while I might have diminished 
the weight of my own remarks by intermixing them with the 
authorities which I only found long after this essay was written, 
I might not also have derived from those authorities the same 
support as I now hope to receive by exhibiting them in one un- 
mixed mass. I shall now therefore, as on other occasions, se- 
lect from authors, such facts on this subject as appear to me 
sufficient, while they are the most illustrative or valuable; some 
among them comprising cases which are parallel to my own, 
and the others being instances of simulation or anomaly which 
have not occurred in my own experience; and all tending, in 
different ways, to demonstrate or confirm the great importance 
of these views. 

Sauvages, indeed, in the fifth class of his etiological arrange- 
ment, appears to promise an entire elucidation of this subject, 
when, in forming a list of intermittent diseases, he passes cen- 
sure on those who have neglected them, holding out the cure by 
means of bark as being certain, when they are known. But 
when we inspect this list, we find a mixture of trifling refine- 
ments, consisting of mere terms, with some of the disorders in 
question, but with others also, perfectly irrelative; while the 
conviction of his want of accurate views respecting the subject 
is completed by the lists of diseases in some of his other classes, 
and by the utter confusion with regard to them which pervades 
the descriptive part of his still valuable work. 

I will commence with a remark of Celsus, which, rather than 
pretend to decide on its absolute meaning, I shall submit to the 
judicious reader. It is, that fever is often very wonderfully an 
advantage, removing "praecordiorum dolores," " jecinoris dolo- 
rem," " nervorum distensionem rigoremque," and "difficulties 
urinas." This is obscurely expressed; but it seems to me to im- 
ply the fact formerly stated, that the local affections belonging 
to intermittent, often disappear in consequence of its assuming 
a more decided and regular form. When Van Swieten describes 
obstinate headachs as cured in the same manner, when a case of 
palpitation thus removed by an intermittent is described in the 
Memoires of the Acad, des Sciences of Paris, and when Strack 
relates a case of asthma cured in the same way, there is no rea- 
son to doubt that these are all instances of the same nature as 
those which I have described; while, that they have not been thus 



198 OESCURE INTERMITTENT?. 

commented on by the narrators, is a proof that they had not 
understood what I have here been attempting to inculcate, and 
that even Strack, who seems to have come nearer to the truth 
than any one else, from the multiplicity of his cases, had not 
formed for himself a definite view of the nature of anomalous 
and simulating intermittents. Where, further, and reversely, 
different authors, whom I need not quote, lest I should unneces- 
sarily prolong these authorities, relate instances of the change 
of intermittent into some other disorder, and of its apparent 
cure in this manner, and when Strack, especially, notes an in- 
termittent thus cured by a dysentery, the explanation is the 
same, and the last instance in particular, too obvious to need 
one. 

Such substitutions, or apparent changes of the intermittent 
into a new disease, have also been cured by bark; yet even then, 
very often, as far as we can discover from the narrator's expres- 
sions, rather by a conjectural or empirical proceeding, than from 
any clear conviction of the nature of such disorders. Thus 
does Werlhoff name palpitation of the heart, and also rheuma- 
tism, succeeding to intermittent, and so cured. 

As far as I have read, it appears to me that Cleghorn had ar- 
rived nearer to the truth than any one else; yet if he was aware, 
in his day, of what I have, as I trust ascertained on this subject, 
he does not express himself fully; while, that what he has said 
has made no impression, is apparent from the present state of 
opinions; not merely from the neglect of this subject shown by 
all the more recent authors, whether writing on the intermittent 
itself or on the diseases which it simulates, and not merely also 
from that of practitioners, but from the ridicule, already noticed, 
which many of the former throw on the nosologists for noticing 
these varieties; treating them with contempt as unnecessary re- 
finements. Thus this able observer remarks that the intermit- 
tent is often accompanied by pains resembling those of pleurisy, 
phrensy, hepatitis, and lumbago, when the remissions are ob- 
scure; while he seems to hint that a marked symptom of this 
nature sometimes obscured the proper fever, and was a source 
of error by affording ground for wrong names. And I conjec- 
ture also that the same conclusions had been formed by Senac, 
and others of the older authors, when they describe cases of pe- 
riodical headach, periodical delirium, and periodical coma, with 
or without fever; though, possibly, for want of a more definite 
generalization, these have been overlooked by their successors. 
To proceed with cases confirmatory of those which I have my- 
self observed. 

I have remarked that I had seen an obscure intermittent, mis- 
taken for phthisis, more than once. To confirm this, I may 
quote Strack, who refers to many instances of the same nature: 



OBSCURE INTERMITTENS. 199 

all the symptoms, including cough, having been present, while 
the proof was as complete as in my own, since they were cured 
by bark. One case of this sort in a female, which he relates, is 
a proof both of his sagacity and resolution; because the sister 
had died of an hereditary consumption, and the father was la- 
bouring under one. Thus also, Morton, Werlhoff and Tralles 
describe a phthisis produced by or succeeding to intermittents, 
attended by the usual symptoms of that disorder, and success- 
fully treated by bark: and an anonymous author quoted by Sau- 
vages, similarly speaks of numerous cases, attended even by 
spitting of blood and pleuritic pains, which were decidedly pe- 
riodical in their attacks and as regular as intermittents, and which 
were also cured by the same remedy. 

Here is one example therefore, and as it happens, in the very 
first of these simulating, or, in another sense, simulated, disorders 
which chance has brought uppermost in these illustrations, 
where the authorities are as numerous as they are decisive and 
weighty. And yet is this one of the disorders, very especially, 
respecting which the greatest incredulity has been expressed. 
These at least are names which are not very safe objects of ridi- 
cule: it will be for the judicious and philosophical physician who 
may attend to this subject, to doubt whether a different accusa- 
tion might not be retorted on those who may nevertheless be 
left to their own reflections on that subject, as on all else which 
belongs to this question. 

On the subject of catarrh of this nature, if, in suggesting that 
a certain summer disease of this kind might arise from this 
cause, I referred to the catarrhalis of Sauvages, I must here re- 
mark that the cases quoted under this term are of a different na- 
ture, inasmuch as more acute, both in the local affection and the 
fever, while of such varieties I have no experience. The cases 
cited by different authors are, however, numerous, and leave the 
question beyond a doubt. In some, it is so severe as to pass 
into peripneumony, still betraying itself by an intermittent cha- 
racter, and cured by bark. Monfalcon, as well as Strack, seems 
to have been familiar with this variety. And a very marked 
case is noticed, which serves to indicate distinctly the true cha- 
racter of sucli a catarrh; the peculiarity being, that in a tertian, 
on the day of the paroxysm, the cough was dry, and on the 
other, loose. 

To confirm the cases of dry spasmodic cough of the character 
which I have noticed in my own practice, I find in Monfalcon 
what he calls a pertussis, as a very common occurrence, preced- 
ing the paroxysm of intermittent, and cured by bark. Strack 
also describes a dry spasmodic cough of this kind; but both he 
and Monfalcon seem to have noticed such a disease, only whore 
there was also a marked intermittent fever present; bemti ap? 



200 ^ OBSCURE INTERMITTENTS. 

parently unaware of the cases, even more important in practice, 
because less suspected, where there is no intermittent fever sen- 
sible, and the disease is a mere periodical cough. 

I spoke at some length of a pleuritic pain attending an ob- 
scure chronic intermittent, or as being a substitute for it, often 
grossly mistaken in practice; and I then referred it to the pleu- 
ritica of Sauvages. I must however remark here once more, 
that his pleuritica is always an acute disease, or belongs to a 
well-marked, and generally a severe fever, either intermitting, 
or a proper remittent. Fernelius, Morton, and Strack appear 
also to have noticed no other cases: but such is their conviction 
of its true nature, that they decide freely on curing it by bark; 
a recommendation which has been little followed, or rather has 
been entirely forgotten, by almost the whole mass of practition- 
ers of our own country, and indeed often elsewhere; since this 
is one of the cases where blood-letting is especially recommend- 
ed and especially abused. 

Of the arthritica, I have spoken but slightly, having had no 
experience of any value. But Strack appears to have often met 
with this variety, and in a very marked form. In some instan- 
ces, the pains have been universal, but shifting; in others, they 
have been periodical and regular; in others again, unintermitting, 
and steadily affecting different parts; while, very often, entirely 
without fever, so as to have caused the usual deceptions. In 
these cases, the proof has, as usual, consisted in the success of 
the remedy, bark. On this variety I must further remark, that 
it might as properly perhaps be termed the rheumatica, while I 
need not point out how it illustrates what I have said respecting 
rheumatism, whether acute or chronic, without fever or with it, 
constant or intermitting, and of its cure by bark. If Rush also, 
not very amenable to the opinions of others, finds that there is 
a rheumatism of this character, it will be for practitioners to re- 
flect on what I have said formerly respecting that disorder, and 
to see whether they have not very often persisted in a wrong 
and pernicious practice as to it. If I find further, that Strack 
notices a gout of this character, it is to this that the term arthri- 
tica should rather, and in strictness, be applied; unless it should 
be reserved for the rheumatism of the joints, should that disor- 
der be ever proved to belong in any instances to this division; 
while I have, myself, no experience as to this variety. 

As to the nephralgic intermittent, I must refer to Morton, as 
I must confess my inability to understand that variety as it has 
occurred to him. I have been obliged to notice it elsewhere, as 
being probably a neuralgic pain; but the disorder as mentioned 
by him, seems rather to belong to the inflammatory varieties of 
intermittent, and to rank with those which I have here been no- 
ticing. 



OBSCURE INTERMITTENTS. 201 

To pass from these inflammatory varieties of the intermittent, 
I find that Strack quotes a case of atrophy, or inexplicable de- 
bility, which had been attributed to grief, and was cured by 
bark. This confirms the similar cases which have occurred to 
myself, when unaware of his remark; in two of which, grief 
was similarly a preceding circumstance and the imputed cause. 
It might indeed be a real one, even on this view of such cases; 
because that mental affection will reproduce chronic intermittent; 
as it might, when united to the ordinary cases of intermittent, 
give rise to a new disease, the character of which, it is not diffi- 
cult to understand, might be modified by the state of the mind; 
this disorder being, as it is, so essentially connected with the 
nervous system. 

If I have also noticed that menstrual irregularities are fre- 
quently produced by the chronic intermittent, or remittent, (it 
is indifferent which, for the present purpose,) I find this also 
confirmed by the same author. Ordinary obstructions, menor- 
rhagia, and irregularities, have thus occurred to him as to me; 
cured by bark under his care, as, by myself, by different means 
directed to the fever and not to the apparent disease. Chlorosis, 
an almost necessary consequence in certain cases, is equally no- 
ticed by him; while he also points out, what I have not seen, a 
periodical monorrhagia accompanying the quartan paroxysm. 
When he mentions that, in nurses, the milk is often suppressed 
hy an intermittent, it is a case which I may quote on account of 
its analogy, but of which I have not seen an example. 

I also remarked formerly, that a hectic fever, attributed to in- 
cipient phthisis, to scrofula, or to obscure visceral disease, was 
often supposed present, when the real disease was the chronic 
quotidian or remittent, leading to no small alarm and considera- 
ble errors of practice. I find that Strack, to whose support I 
am so much indebted, had made the same remark; while I may 
add here, what I then omitted, that in addition to the ordinary 
tests for distinguishing intermittent of this character, it must be 
remembered that the recurrence of true hectic is in the evening, 
and that the great majority of intermittent paroxysms recur in 
the morning. 

The presence of dyspeptic symptoms in the chronic remit- 
tent, was another occurrence formerly pointed out, together with 
the erroneous practice which resulted from overlooking the real 
disease. If I do not find any exactly similar remark in the au- 
thors whom I have consulted, I find however what fully con- 
firms the possibility of such a state of things. It is stated by 
Montluet as being a common disease in the pestiferous tracts ot" 
the Lyonnais, and, generally, as of a severe character; though 
he does not notice the chronic fever, which however we know 
to belong to nine in ten of the inhabitants of those districts, u 

26 



C'02 OliSCUfiE INTERMITTENT!*. 

the necessary endemic. Very naturally, according to the pre- 
vailing theory in France, he attributes it to gastro-enteritis of 
gastritis, which, in reality, may well exist to a certain extent, as 
it unquestionably does in many of the cases of even ordinary 
dyspepsia. We have the same observation from M. Nepple; 
who adds that though it is at first confined to the stomach mere- 
ly, it extends in time so as to derange the liver also. 

I recently mentioned diarrhea as alternating with intermit- 
tent, or as a substitute for the ordinary febrile paroxysm. I 
have not, as I then said, yet found a parallel case in authors; but 
a diarrhea, decidedly not a dysentery, is noticed by many 
French writers as common in their intermittent districts: a dis- 
order without pain, and generally without fever, often succeed- 
ing to the fever, extremely obstinate, and after a cure, easily 
brought back by slight causes. This, T presume; must be the 
same disorder which I formerly mentioned as occurring in the 
hulks at Woolwich; and it is sufficient to have barely noticed 
the fact, for the purpose of preserving this series of correspond- 
ing observations as entire as possible. In Strack, I find cholera 
enumerated as a disease to be cured by bark; and I might thus 
suppose that he had formed nearly the same view of it as my- 
self, while if I may judge from the practice, this must sometimes 
also have been the opinion of certain English authors. Or thus 
at least, it is probable, must the remedy act, when it is said that 
hark is the effectual medicine in cases of the excessive secretion 
of bile. 

If I find no case of periodical vomiting resembling those 
which have occurred in my own practice, 1 at least see in 
Strack a case of a continued disorder of the same kind cured 
by bark, and therefore probably of the same nature; a misplaced 
intermittent. But with respect to hysteria, he quotes periodi- 
cal disorders of this nature as being very common, confirming 
my former remarks; the types having been both quotidian and 
tertian, and either with or without fever. This is the modifica- 
tion of simulating intermittent, on which he seems most clear; 
censuring Sydenham for recommending bark in all cases of hys- 
teria, and therefore leading us to suppose that this lauded phy- 
sician had actually thus cured cases of the hysteria of intermit- 
tent, without being aware of the nature of the connexion here 
pointed out. 

This terminates the list of cases which I find in authors as 
they had occurred in my own practice: it remains to notice a 
few which I have not seen. 

Periodical hiccup, following a terminated intermittent, is one 
of these; and this I must consider as a species of translation or 
substitution. 

Of neither epilepsy nor convulsions have I met any instances, 






OBSCURE INTERMITTEJSTS. 20S 

but I find them recorded in numbers by different authors. In 
a case of Strack's, the former disorder succeeded an intermit- 
tent, and with the same periodical returns, being cured by bark; 
and it is a further interesting one, by having been followed, 
subsequently to this cure, by a pain of the left leg and a palsy. 
This single case therefore, like many which 1 have described, 
shows the connexion between several of thesp local diseases, 
and their dependence on intermittent; as there is little doubt 
that the pain of the leg was a Neuralgia: though this author 
appears to have been perfectly unacquainted with the nature of 
that disorder, and has consequently left a serious defect in his 
otherwise valuable work. That he must have seen it in many 
other cases than this, is not to be questioned; while I may as 
well remark here as any where else, that of all those authors 
which I have consulted as to intermittent, ancient or modern, 
not one has noticed such a disease, while it is most certain that 
they must all have seen it: a clear proof that it had never been 
suspected to belong to the intermittents, as it could not, in that 
case, have escaped enumeration, and would on the contrary have 
attracted a principal attention. 

Caldera, Bain, Sauvages, and others, also mention the epilep- 
sy belonging to intermittents: but as it is unnecessary to dwell 
longer on this, I may mention that Strack and others have in 
the same manner described ordinary convulsions, especially in 
children, either attended by intermittent fever or not, and the 
returns being, in each case, periodical, while the same remedy 
was successful. One marked case, where, in a girl of seven- 
teen, the • convulsion returned regularly in the quotidian type, 
during nine days, each paroxysm lasting twelve hours, and 
which was also cured by bark, is too explicit a one to be here 
omitted. Of a cataleptic intermittent noticed in Sauvages, I 
know, practically, nothing, and may here be content with the 
term; while to him and his authorities I may also refer for the 
fact, having nothing of my own to say respecting it. 

A periodical colic is noticed by Strack, as if it were a mode 
or a symptom of intermittent. I cannot exactly understand his 
description or views as to this case; but as I have had more than 
one occasion to suppose that the Neuralgia had, in some patients 
who had suffered this disease in various nerves, appeared in dif- 
ferent parts of the abdominal cavity, it is possible that such 
cases may be of this nature. Unfortunately, his ignorance re- 
specting this disease has impeded the evidence which we might 
possibly have received on that subject from him, as to these 
cases. 

I have no experience of a case mentioned by Pacoud as not 
uncommon in the unhealthy parts of the Lyonnais, and which, 
if it is not precisely a transference or misplacement of the in- 



~04 OBSCURE INTERMITTENS. 

termittent, is too nearly allied to such cases to be passed over. 
This is the alternation of ulcers of the legs with periods of the 
fever: and it is at least evident that it bears an analogy to all 
those cases, such as that of palpitation formerly pointed out, in 
which, when a local direction or symptom occurs during a chro- 
nic intermittent, the fever disappears, or becomes so slight as to 
attract no notice. 

I have here described a palpitation of the heart of a very se- 
vere character, as one of the modes of intermittent; but unless 
the case which I have just noticed as existing in the Mem. Acad. 
Sciences is one of the same nature, I find in authors no cases of 
this kind: a proof that wherever they have occurred, as could 
not fail, they must have been misunderstood. There is indeed 
a notice of a similar case by Storck, but in that one there was 
an acute fever. Nor can I doubt but that if physicians had ta- 
ken the view which I have done of this class of intermittents, 
and very particularly had it been known to the numerous au- 
thors on this disease, especially to those of France and Italy, 
where the opportunities of observation must exceed by a million 
of times any which England can offer, I should have been easi- 
ly able to produce hundreds of cases in confirmation, where I 
have with difficulty found one; and it is very probable also that 
I should have materially extended the list of these simulated 
diseases. 

There is one yet remaining, however, and that is, amaurosis. 
It is noticed by Storck, and also by Davidson; the disorder, in 
this latter case, returning with each paroxysm, and resembling 
therefore the intermitting palsy of the limbs mentioned when 
treating of that modification. That these cases are highly in- 
teresting, even as to the history of palsy, by showing how this 
extraordinary fever can influence a single nerve, and how singu- 
larly it can exert that influence, I need not urge here; but I con- 
sider them also of value, from the bearing which they appear to 
have on Neuralgia. Hereafter, I shall have occasion to show 
that this disease is the similar localized action of an intermittent, 
and that r in it, pain and palsy are intimately associated. And 
if I shall then also have occasion to suggest that amaurosis may 
be the produce or consequence of a Neuralgia which has occu- 
pied the eye, that suggestion will find no small confirmation by 
the present facts; while it may eventually also be proved by fu- 
ture observation, that this very obscure disease, amaurosis, is 
sometimes at least, and possibly much oftener than even I am 
inclined to suspect, connected with or dependent on intermittent 
of irregular character. 

In terminating this part of the subject, since I cannot fail to 
be aware that it will, as well on a general view as in many of 
its details, if not in all, appear matter for doubt and incredulity. 



OBSCtJRE INTERMITTENS. 20$ 

and especially to those who have not studied or been familiar 
with intermittent fever, it might be proper, and possibly use- 
ful, to give a general view of the reasons, a priori, why that 
which appears to me to be proved by evidence, may be true, or 
ought to be true; to confirm by a general view of the action of 
the assumed cause, the facts here referred to that cause, as be- 
ing in reality such as ought to arise from it. 

To do this however effectually, and by a perfect induction, it 
would be necessary that we should be able to assign the proxi- 
mate cause of intermittent, or that primary change in the func- 
tions of the body, or in the parts affected, which is produced by 
Malaria. Here however we are at a stand; or the very founda- 
tion of a complete philosophical induction is wanting; since, 
under the head of remittent, I have already shown that we are 
ignorant of the nature of this first effect, or of what, in medical 
language, is called the proximate cause. 

I must therefore leave this part of the history of intermit- 
tent, a subject which generally occupies so conspicuous a place 
in medical systems, a blank, otherwise than as I have already no- 
ticed it in the case of remittent; since I have never been able to 
discover how knowledge is augmented by loose conjectures and 
by unmeaning terms and substitutions of terms. But that ig- 
norance, the want of the fundamental step, does not prevent us 
from tracing useful analogies beyond this first foundation; while 
we may even safely and philosophically venture to do this by 
the adoption of an unknown effect or cause; effect on one side 
as it is cause on the other; or, to derive an illustration from ma- 
thematical reasoning, by the substitution of an unknown quan- 
tity. If useful truths are thus elicited in this department of 
philosophy, so may they be in the present case, and on very 
similar principles. On that ground, my task will be to prove, 
that the cause which operates on the whole nervous system, pro- 
ducing a certain effect which is the unknown quantity and the 
cause in this case, does operate also on less than the whole, and 
further, on its separate portions: that the visible effects are a 
joint result of this unknown action, and of the nature, or natu- 
ral condition, or offices, of the different portions of the nervous 
system thus affected, and that these are the diseases under re- 
view; and, further, that the analogies which pervade the whole, 
are such as confirm the proof of a common, if unknown, cause 
and effect: acting in an analogous mode on nerves performing 
different natural duties, rendered thus diseased, and each disease 
being varied in consequence of the nature or functions of that 
particular portion of the nervous system which is thus de- 
ranged. 

To be able to form such an induction, would be, it is plain. 
to add the philosophical reasoning, and the proofs, a priori. tc> 



208 CUKE OF 

the evidence; and to give to the whole system that form whtcfi 
philosophy demands, and which will not be without value, though 
the actual proximate cause should for ever remain unknown. 
Even to approach to it, is to give a certain stability and unity 
to the present views; since it is an approach to that perfect ge- 
neralization which constitutes science, and with a modified de- 
gree of which we are often compelled to be content, in sciences 
far more within our reach than physic. This is the attempt that 
I propose to make; but as it will be convenient first to describe 
all the other diseases which I have been induced to rank under 
the same cause, I must defer it till those have been discussed. 



CHAPTER Vffl. 

On the Cure of Intermittent Fevers. 



The cure of intermittent fever in its common forms, or ra- 
ther the remedies that are in use for it, are all so well known ? 
that my task here will be but to repeat, since I have nothing 
strictly new to propose on that subject. It will be useful how- 
ever to examine some of the remedies at a little length; for 
many reasons, and among others, for the light which they throw 
on the nature of this disease. On what may belong to the cure 
under the anomalous forms already described, the remarks will 
be best introduced where they will add the most illustration. 

It is a somewhat lax and theoretical division of these remedies 
which I must here adopt, because I cannot easily discover a bet- 
ter one; as a true one could not indeed easily be formed, with- 
out knowing previously in what the disorder really consists, and 
without knowing, further, how medicines act on the body: a 
species of knowledge in which physic is as yet very deficient. 
The most obvious division then at present, is into those reme- 
dies which act on the mind alone, or on the nervous system 
through it; those which seem to act on that through the body, 
and the effect of which is judged to be solely on that system, 
from its rapidity; the tonics, which, if they do thus act, may be 
supposed to exert some other power also, or that power in a dif- 
ferent manner; and lastly, changes of habit, be the nature of 



INTEKMlTTENTo 207 

those changes what they may, Of other remedies, such as 
blood-letting, not to be ranked under any of these heads, and 
very generally, of incidental or extraneous utility, if I may 
use such a term, I must treat separately as I best can. 

It is here, however, very essential to commence by distin- 
guishing between the simple and the chronic intermittent, or 
between a new disease and an habitual one; as the remedies that 
are effectual in the first, act with much less power in a disease 
that has relapsed or returned, and as, in cases of long duration^ 
they seem to lose their power altogether; while it is from con- 
founding those two very distinct conditions under one general 
term, that so many useless remedies are applied to the latter, 
and that so many failures occur, even in the use of valuable 
ones. I know not, however, that any distinction is necessary as 
to the types of intermittent; since, in all of those, the remedies 
are the same, requiring only to be regulated differently, by con- 
siderations drawn from the occurrences and lengths of the pa- 
roxysms and the intervals. Let me also here premise, that 
while I do not propose to discuss this subject as to the severe or 
malignant intermittents of hot climates, whether these be sim- 
ple or complicated, so, in as far as this mode of marsh fever ap- 
proaches to remittent, the methods of cure have been already 
examined, though it will here be impossible to avoid some repe- 
tition. 

The simplest remedies are those which act on the mind, or 
through it; while their number is far greater than I choose here 
to record. But while there can be no doubt of their powers, 
and therefore of their value, it must be remarked that these are 
the remedies above all others, the action of which is limited to 
new diseases, or to those which have at least not relapsed often; 
while they are, further, scarcely ever successful, except where 
all the circumstances of the disorder are regular. Thus also do 
they appear to succeed better in tertians than in quotidians; 
while there seems no certain experience of their success in re- 
mittent. I ought to add also, that their action requires the be- 
lief or the confidence of the patient; or, Faith; without which, 
they are invariably nugatory, otherwise than as any other strong 
mental impression, such as disgust, fear, and so forth, may be 
the substitute for this. Thus it is that superstitious practices and 
charms, which succeed with the vulgar and ignorant, are utterly 
inefficacious with the incredulous, or with those who may pos- 
sess a superior education; while among those, however, certain 
nugatory remedies will cure the disease, by inspiring that con- 
fidence to which either ignorance or false reasoning is necessary, 
when they fail w T ith superior minds, capable of reasoning re- 
specting causes and effects. In whatever way these remedies 
act, the fact itself is an important one as relates to the theory 



iOS CURE OF 

of the disease; since that action, and the mode of it also, the 
suddenness, among other things, go far to prove that it is si- 
tuated in the nervous system, or in the brain and nerves; and 
that to influence that system, directly and solely, is the cure, 
and probably the end to be aimed at by every remedy. 

The charms used for this purpose, consist in mere words, 
spoken by some person reputed to have powers akin to the 
witchcraft of the days of superstition, or in texts of Scripture 
or other words attached to the person, like the periapts of anti- 
quity, and the fetiches of Africa; contrivances among which the 
mystic word Abracadabra is or was one of no small note. Amu- 
lets, equally successful, are the remains of a very general prac- 
tice, still preserved, if unwittingly, in the coral and bells of 
children, in the ear-rings of the French populace and military, 
and, with the open acknowledgment of superstitious folly, in 
the anodyne necklace even now used for dentition in children, 
and by those also who are reputed to be possessed of sense and 
education. Thus also is a piece of glazed or cambric pasteboard 
alone, found to be a cure for tertian; as are many more applica- 
tions equally inactive as medicines, which it would be a waste 
of time to enumerate; since, provided the superstitious confi- 
dence of the patient can be excited, the application itself may 
consist of any thing. An endless number of plasters, appear- 
ing to possess the active medicinal qualities which they have not, 
might be added to these, as of more extensive powers; since 
they excite, by their names or sensible properties, the necessary 
confidence, in a class of persons far above the most superstitious 
and the lowest vulgar, at least in rank, if not always very 
strongly distinguished from them in mental powers. 

Under this head, if I mistake not, I must also class avast ca- 
talogue of internal remedies; medicines of the most discordant 
properties or of no properties at all, but having equally gained a 
degree of reputation, greater or less, from occasional or partial 
success depending on this principle. These form that mass of 
trash with which old women, of whatever sex, torment their 
neighbours, with that intrusive self-conceit which belongs to all 
voluntary empirics, and against which it is in vain to remonstrate, 
by showing that their utility is nothing without confidence on 
the patient's part, and that, in the chronic disease, they are ut- 
terly void of power, even over imbecility and ignorance. 

Not to enter into an enumeration of a catalogue with which I 
might fill many a page, and where I might even commence with 
Cato's prescription, a formula well worthy of ranking with the 
balsam of Fierabras, I am even of opinion that bark itself some- 
times acts in this manner; an effect not very improbable, when 
the universal confidence in it is considered. It is possible, I 
will not deny, that the celebrated Sicilian remedy, powdered 



INTERMITTENT. 209 

charcoal, may have some medicinal effect, but it is also not un- 
likely that it acts solely in this way, since it seems to have no 
action on the system and to undergo no changes in the body. 
With respect to spiders or other remedies exciting mere repug- 
nance, they may act on the faith of the patient; but they seem 
rather to operate by exciting disgust, one of the strong mental 
impressions which removes this disorder: and this 1 also conceive 
to be the action of cobwebs, which, containing much ammonia 
united to some highly putrescent animal compound, form an ex- 
ceedingly nauseous medicine. 

Thus also does a strong mental impression produced by mo- 
ral, and not by physical causes, cure the intermittent, or at least 
remove a paroxysm in similar cases. This effect has often been 
produced by fear, by the sudden necessity of exertion, by hope, 
or by joy, by unexpected success, and even by sudden grief or 
disappointment; and if in a recent work of African travels, the 
power of the sudden presence of a beautiful woman in thishian- 
ner may excite a smile, there is no reason to doubt the truth of 
the narrative, as it is by no means a solitary case. I have only 
to add that in all such cases, the cure of but one paroxysm is 
often the cure of the disease; as if it was a habit not yet so firm- 
ly established, but that the mere interruption of it was a suffi- 
cient remedy. 

With respect to the effect of charms, however, it is yet ne- 
cessary to add one remark, for the sake of the higher vulgar, 
who are apt to lay too much stress on their efficacy: not perhaps 
on that of cambric paper, spiders, and abracadabras, but on me- 
dicines of apparent power, the action of which is, in reality, on 
the imagination. It is this; that the ague which is the most se- 
vere, is, in fact, very often the slightest disorder, paradoxical as 
that may seem. It is a disorder which is most violent in its 
commencement; or the fever, as the most perfect and regular, is 
then the most distressing, both to the patient and the spectators. 
But severity and obstinacy are different things; and thus also 
though a new disease is more severe in general than a relapse, 
it has not the same persistence. It is the ancient and chronic 
case which appears slight to the by-stander, and which, what- 
ever the patient may suffer under it, is, even to him, not such a 
cause of absolute disability as a new disease. Yet this is pre- 
cisely the case in which it becomes incurable, or difficult of 
cure, resisting medicines as well as charms: while the vulgar, 
naturally enough according to their own ignorance, conclude 
that what cures a severe disorder must, a fortiori, be even more 
efficacious in an apparently slender one. 

The next division of remedies, may be sought in those winch 
do act powerfully, and suddenly also, on the body, and through 
that on the nervous system, but whose action is tcmporarv. 

27 



210 CURE QI- 

With respect to the whole of those, their effects on the disease 
seem to be restricted to their action on the stomach immediate- 
ly before the accession of the paroxysm, or at least not long 
after its commencement. Their palpable effect is that of short- 
ening or preventing the cold stage, and inducing the hot one; 
or else of shortening or diminishing the force of the whole pa- 
roxysm, or finally of preventing its occurrence altogether. 
Thus does the interruption of one paroxysm sometimes termi- 
nate the whole disorder; and hence such remedies act in some 
cases almost like charms; acquiring, in consequence, in the eyes 
of the ignorant and of the self- constituted prescribers with which 
the world abounds, a universal reputation which they are far 
from meriting. Occasionally, by repeating them before subse- 
quent paroxysms, should they not entirely succeed at the first 
exhibition, they gradually reduce the force of these, and thus 
the disorder disappears. But it is very rare, that, in the chro- 
nic and confirmed intermittents, they do more than remove a 
single paroxysm, or diminish its inconveniences. 

As to the medicines themselves of this nature, they consist of 
a variety of substances commonly considered as stimulants; and 
under whatever forms or combinations they may be given, or of 
whatever they may consist, alcohol, opium, and spices, will re- 
present the whole. Brandy and pepper, brandy and laudanum^ 
brandy with capsicum, or gin, or rum, or large draughts of hot 
wine, with spices or without, will serve as sufficient specimens 
of these remedies under their popular forms; while physicians 
need not be told under how many shapes they may be extracted 
from the pharmacopeia. Among these remedies before the fit, 
or at its commencement, I ought not however to omit the ap- 
plication of the tourniquet to a limb; but as it does not appear 
to have produced the advantages which were asserted by the* 
person who introduced it, it seems to have fallen into just neg- 
lect. 

This may suffice for a class of remedies, of which the appli- 
cation, to be useful, must, in most instances, be made before the 
fit, but of which, some also are applicable during the early part 
of it. If I could not make a division which would not have 
had its inconveniences, I must now therefore describe the treat- 
ment, as far as it is simply and rationally medical, through the 
paroxysm; yet while noticing bleeding and some other matters, 
mentioning them merely as they relate to the time of using them^ 
and reserving till hereafter, that discussion as to their merits 
and utility, which, from its length and intricacy, requires a se- 
parate place. 

The treatment in the paroxysm is rather palliative than cura- 
tive. Warmth and warm drinks in the cold fit, the reverse in 
the hot one, with rest and silence, comprise the ordinary con- 



INTERMITTENT. 211 

flluet necessary. In the former, purging, and still more, bleed- 
ing is improper; this last even causing sudden death. Emetics, 
however, will frequently bring on the hot stage, as, given be- 
fore the cold one, they sometimes prevent the paroxysm; which 
also, I may here remark, is often brought on when not actually 
impending, by cold drink, by exposure to cold, and by mental 
affections of various kinds. I cannot discover the purpose of 
blistering on account of delirium, in the hot stage, because that 
will terminate before the remedy can act; while in any view, it 
is an idle suggestion, except in the severer diseases of hot cli- 
mates, where local affections of the brain are demonstrated or 
rendered probable by the character of the epidemic. It is in 
the hot stage that purgatives are best administered; and this is 
also the period for blood-letting, when that is judged proper. 
Nauseating doses of antimony, and opium, are among the re- 
medies applauded by many, in this stage; but while we, in Eng- 
land, are ill entitled to judge of their value in the malignant or 
severe intermittents, they seem unnecessary, to say no less, in a 
general class of disorders, the cure of which is intrusted to the 
remedies given during the intermission. This remark may 
equally apply to sudorifics. I shall proceed to the question of 
bark and of the other remedies used in the intermission, before 
I examine further into the value and use of the means now de- 
scribed. 

The last division of the acknowledged remedies of intermit- 
tent, consists in the medicines which are called, it would not be 
very easy to know why, tonics. These may all be included 
under vegetable bitters, astringent vegetables, and metallic sub- 
stances supposed to possess an analogous power; it would be 
equally difficult to say on what grounds, so unphilosophically 
lax are the ideas attached to the term tonic. At the head of 
each of these three divisions, we may place, respectively, the 
nux vomica, the Peruvian bark, and arsenic; and if numerous 
other substances can be mustered in each division, I know not 
that there is any reason to consider them in any other light than 
as varying in power, while under each head, all of them seem 
to be less effectual than the three which I have named. 

I need not now give a catalogue which every pharmacopeia 
can furnish; but it is necessary to explain the mode of adminis- 
tration. This is, to give the largest quantity which can be taken 
without offending the stomach or producing disturbance, (since 
the rule seems the same for all,) during the intermission, and to 
avoid their use during the paroxysm. This rule, however judi- 
cious, must not however be drawn too strictly; as in the case of 
short intervals, such as too often occur in the quotidian type, it 
II necessary to break through it; in which case I must however 



212 CURE OF 

say, it is always best to avoid the use of such medicines during 
at least the cold stage. 

It is not within my plan to waste words on the discussion of 
doses and formulae, any more than on the varieties of these me- 
dicines; as such matters abound in every treatise: but I ought to 
observe that it is often useful, particularly in the cases of a vio- 
lent paroxysm with short intermissions, and especially in the 
quotidian, to unite this class of remedies to the former; or to at- 
tempt to weaken the paroxysm, so as to diminish the duty ex- 
pected from the other remedies or to gain more time for their 
administration. 

If this is the most generally adopted, and also the most gene- 
rally efficacious of the different classes of remedies used for the 
cure of intermittent fevers, I must still, as before, limit their 
efficacy chiefly to new or simple cases, or to those which have 
not become a confirmed habit. It is a lamentable truth, that 
they are of little efficacy when these disorders have become 
chronic, and that they seldom produce any effect whatever on 
a disease of long standing; such an opprobrium does the con- 
firmed intermittent remain to physic and physicians. 

This constitutes all which it seems requisite to say at present 
respecting the general treatment by means of the acknowledged 
medicines, as I must hereafter quote a few opinions on this sub- 
ject: but a few remarks of an explanatory nature will still be 
useful. These relate chiefly to bark and to arsenic. 

If, in much of foreign practice, it is the custom to give as 
large a quantity of bark as can be taken, within one, two, or 
more intervals, and then to cease; recommencing at some dis- 
tance of time, should it fail, it is more common with us to give 
it in less quantities, and to persevere without limit. It is diffi- 
cult to decide always on the comparative advantages of these two 
modes, from the great differences in the character of the disorder. 
But, while I must return to this question immediately, one re- 
mark seems well founded, however often neglected; and it is, 
that the perseverence in bark beyond a few days is nearly use- 
less; while, if it has been said that whenever it offends the sto- 
mach it produces no good effect, this is contradicted, as I shall 
presently show, by other physicians. And further, it seems 
often true, while even less known, that where a large dose is 
inefficacious, a small one is often useful; or, in reality, that ten 
or fifteen grains will sometimes produce a better effect than a 
drachm. Of the various preparations, the now common com- 
bination of kina, its sulphate, seems the only one which deserves 
a preference to the bark in substance, while it will probably 
prove to be in every instance preferable. 

Having thus simply stated the use and application of bark, 



INTERMITTENT. 213 

whether in remittent or intermittent, since the same remarks 
apply generally to all the modes of marsh fever, I must now 
quote from authors some particular opinions on this head, leaving 
to the judgment of the reader to decide for himself on what 
would involve endless questions and criticisms. A treatise that 
should attempt to strike the balance among opinions in physic, 
would never end: but a writer does not perhaps perform all his 
duty, if, after giving what he conceives is best, and what he 
thinks sufficient, he does not at least inform his reader what 
others also have thought. But even here I must select, for, 
even here, I should fill more pages than enough with variety 
and discordance. 

Millar, Jackson, Lind, and many more, agree that bark does 
not produce visceral obstructions, but, on the contrary, prevents 
them, by checking the fever, which is their true cause. Brock-, 
lesby and Strack proceed even a step further; since they say, 
that, even after the cure of the fever, this remedy removes the 
obstructions of the spleen, and that it is even the best mode of 
treating the consequent dropsy. On the other hand, there are 
authors, perhaps even more numerous, who assert that the bark 
is the real and efficient cause of these obstructions; while, not 
to quote minor facts and authorities, I shall content myself with 
Ramazzini, who, in accusing the bark of producing dropsies in 
this case, quotes at once, an instance of four hundred soldiers 
becoming thus diseased, in one mass, and in a few days, in con- 
sequence of its use. If we should be inclined to think that the 
Italian here proves too much, we must also recollect the preju- 
dices so long and bitterly entertained against this remedy; while 
we must also remember that to confound causes and effects is 
not very uncommon, that there is a considerably assimilating 
power in hypothesis, thatgastro-enteritisis, with some, the cause 
of fever as of all other diseases, and much more which I shall 
leave to the judgment or discernment of the reader who has al- 
ready at least discovered my own opinion, and can therefore re- 
quire no more of my criticism. Whenever I find myself over- 
whelmed by facts like Ramazzini's, I always recur to the phy- 
sician whom I once heard at the Institute, in Paris, who proved, 
by some thousand cases selected from Italian and French hos- 
pitals, that no intermittent fever ever lasted beyond fourteen 
days. 

With respect to the administration of this remedy, opinions 
#re not less various, and often not much less contradictory. A 
few must suffice as specimens; while the reader must, for the 
most part, exert his own ingenuity in trying to reconcile or ac- 
count for them. 

It is always unsuccessful when bleeding is necessary, says 
Rush: it is always pernicious or destructive, say the majority of 



214 CURE 01 

French practitioners; while, unluckily, the preliminary que^ 
tion as to bleeding, is not in itself agreed on. Gastro-enteritiSj 
inflammation of the stomach and bowels, one or other, or all, 
is the cause of the fever, is the very disease itself, according to 
present France: and the theory being thus settled, it is obvious 
what the practice must be. An equal number prescribe it from 
the beginning, even in decided continuous fevers of this cha- 
racter, and in all cases except where demonstrable inflammation 
is present: nearly as many have proved that it is the remedy, 
even for the inflammatory state first quoted; or whence does it 
cure the disease at all, and why does it cure the intermittent 
ophthalmia? 

Of minor matters; as to doses, Millar has given an ounce in 
a dose; Jackson, two ounces in eight or ten hours, in bad re- 
mittents. Cleghorn delayed it till the fifth day in tertians: many 
hundreds give it after the first fit, and often succeed in thus 
stopping the disease. If the intermission is short, it must be 
given through the whole fever, say some: in that case, say others, 
it is not to be given at all. Need I quote Pringle, Hillary, 
Brocklesby, Balfour, Johnson, and hundreds more, for examples 
of such differences? must I not rather say, that if there are pre- 
judices, if there are hypotheses, and if there also are ignorance 
and bad observation, there are really differences of climate, con- 
stitution, seasons of fevers, which if they will not justify all 
that has been said on opposite sides, will at any rate teach us 
to be cautious in judging of what we have not seen, and 
should induce us of the medical profession to cultivate a little 
more forbearance towards each other's opinions than is very 
customary. 

It is a variation of practice, worth noticing here under the 
head of authorities, since I have no experience of it, that in 
France, it is very common to increase the doses gradually through 
the intermission, or if it be long, not to commence at all till 
within six or eight hours of the expected return. Lastly, since 
I might not easily end on this subject, if it is a very prevailing 
opinion that bark is ineffectual unless the primse viae have been 
previously cleared, the French consider this as utterly unneces- 
sary; while when Millar and many more assert that this reme- 
dy is useless should it purge or vomit, Jackson and Munro are 
equally decided that it is just as efficacious under those circum- 
stances as when it is retained. And the former of these au- 
thors asserts, that no man dies of fever who has succeeded in 
taking two ounces of bark. 

With respect to the varieties of the bark, after all that I have 
read or seen, I do not feel sufficient confidence to discuss their 
relative merits, and shall therefore trust to the reader to discover 
for himself the truth, if he can, as to the pale, the yellow: and 



INTERMITTENT, 215 

the red bark, the Jamaicensis and the Caribbea. Yet if kina is 
the efficient substance in Peruvian bark, it is plain that the yel- 
low bark must be the superior remedy, since that variety con- 
tains a larger proportion of this essential salt, than any of the 
others. Of the value of magnesia or of lime-water as additions, 
I am doubtful: as to that of acids, it rests, for obvious reasons, 
on better grounds. 

As to the bitters, after the nux vomica, it is scarcely necessa- 
ry to enumerate quassia, wormwood, carduus benedictus, snake- 
root, gentian, centaury, chamomile, all of them remedies of a 
certain celebrity in different hands; while angustura, Swietenia, 
eascarilla, Winter's bark, willow bark, galls, oak bark, and even 
alum and more, have had their several abettors, just as, in the 
metallic class, iron, copper, silver, and zinc have taken their 
turns, among those who seek in variety for some mysterious 
powers which they perhaps scarcely acknowledge to themselves. 

I am now bound to make a few remarks respecting the value 
and use of arsenic, which has been lauded beyond its merits, 
and often also condemned and shunned, rather from the fear ex- 
cited by its name than any thing else. That it often offers a 
rapid and effectual cure for the intermittent, admits of no doubt; 
but it is as certain that it very often fails, while the decided pre- 
judices against it, almost every where except in England, which 
have rejected its use, put it out of our power to discover, by a 
proper and sufficient experience, what its real value is. 

I have little therefore but my own experience to judge from; 
and this is, in the first place, that it is less efficacious than bark 
in diseases of a highly febrile character and of long duration; or 
that as the intermittent approaches nearer to the remittent, ar- 
senic becomes an uncertain remedy, and that in the very chro- 
nic disease, it appears to me to possess no power at all; though 
I know not, that, in these latter cases, it is more nugatory than 
any other remedy. In a new and a very simple intermittent, 
and in the tertian particularly, it seems to offer a more rapid 
remedy than bark, while its superior convenience is manifest. 

But if I were to compare it with bark in those cases where 
the disease puts on the anomalous symptoms or characters which 
I have described, I should often judge it a more effectual reme- 
dy than that; and although my own experience is far from suffi- 
cient to decide this point, I have also found it the best medicine 
in all the cases of the most purely local affections, or in the Neu- 
ralgia; not but what it fails much too often, even in these, and par- 
ticularly where they are of long standing. 

In as far as it does fail, there is reason to think that the fault 
is very often in the remedy itself; and I cannot concede that the 
well-known combination of this substance, rather, of its prima- 
ry acid with potash, commonly called Fowler's solution, is the 



216 CURE OF 

proper mode of using it. It is certain at least, that when this 
has failed, the same substance, or the common arsenic of the 
shops, in powder, has often succeeded, and even immediately. 
Of this, the sixteenth part of a grain is an equivalent to the 
common dose of the solution, and capable of being repeated 
three, or even four times in the day; while it is conveniently 
divided by means of white sugar, which also aids in reducing it 
to that fineness of powder which cannot be too perfect. With 
respect to the superiority of arsenic in substance to its neutral 
salt, I may quote the experience of a friend, who, residing in a 
district where tic douloureux is extremely common, and where 
the solution seldom succeeded, now reports to me that he finds 
the powder almost infallible; giving it without the least incon- 
venience to the extent of I -12th of a grain for a dose, and find- 
ing that its utmost limit is I -8th, which can seldom however be 
endured, though having administered l-6th without further evil 
consequences than gripings. 

As this remedy is held to be attended with danger, and also 
with ultimate bad consequences, I must here bestow a few words 
on that subject. When given in excess, short of its properly 
poisonous effects, the symptoms are various, but tho following 
have been observed; headach, sweating, tremors, nausea, vomit- 
ing, griping pains, with spasms of the lower extremities, and, 
sometimes, affections of the urinary passages; more frequently a 
red eruption on the skin, with swellings about the eyes and 
other parts resembling that produced in what is called a surfeit, 
from eating muscles, and, in particular persons, many other sub- 
stances. I must also remark, that, as in this latter case, there 
are individuals who thus suffer from it, even in the minutest 
doses, and that the eruption of the skin appears to be one of the 
most common effects, generally however limited to the face and 
the breast. That effect, together with slight nausea, are the or- 
dinary, and commonly the sole ones, unless the dose be ex- 
cessive. 

These symptoms naturally produce alarm, when the patient 
knows the medicine which he is taking; but I have never seen 
any ill consequences resulting. They are all easily removed 
by brandy, as is the common surfeit, or by opium, and if not, 
they cease of themselves in a few hours. And 1 am entitled to 
judge thus, from having known different patients persevere in 
the remedy for many days, or even weeks, in spite of such ef- 
fects, even when they were very severe; while their occurrence 
does not diminish the useful action of the remedy. It has been 
said that camphor prevents them from taking place; but my own 
experience as to its effects of this nature is imperfect. 

Besides these striking effects, it happens that, after some 
days' use, the effects of arsenic become sensible in other ways: 



INTERMITTENT, 217 

though, even here, I have not found any further inconveniences 
following. The pulse becomes quickened, and the skin hot and 
dry; while there is that peculiar feeling of languor and debility, 
well known as the effect of mercury acting on the constitution. 
Inflation of the intestines, or a swelling of the abdomen, also 
very often attends this condition. If these effects are compara- 
tively endurable by the patient, they seem to be such as could 
not be continued long without hazard; though I have not myself 
seen any further evil consequences. In this case, however, it is 
prudent to interrupt the use of the remedy, and to interpose 
purging, by means of which the effects in question disappear. 

This is evidently an accumulation of the effects of this me- 
tal, analogous to what occurs in the use of mercury; and hence 
it has been argued that the poison might permanently attach it- 
self to the body, so as, even at some far distant time, to produce 
evil consequences. It has been particularly said that it has in- 
duced palsy, or paralytic effects on particular nerves, when thus 
given in Neuralgia. But this is to mistake the result of the 
disease for that of the medicine; since I shall hereafter show 
that such effects are common as following the painful state of 
the nerve, and occur equally whether any medicine or none at 
all has been used. And when I have pointed out how often pa- 
ralytic affections are the produce of intermittent, noting also a 
case of the shaking palsy thus arising, it is easy to see how, un- 
der ignorance as to this natural result, a discredit must often 
have been thrown on this remedy from false inferences. 

Nor is it a sound induction to say, that arsenic must produce 
these effects under the form of a medicine, because when gra- 
dually breathed for a course of years or months, as it is by work- 
men in different manufactories, (but very rarely now that its use 
in glass-making is abandoned) it induces palsies of a local or 
more general nature. In these instances, the dose is incompa- 
rably greater, as is the continuance; and between the two cases 
respectively, there is exactly that similarity which occurs when 
mercury is gradually introduced through the lungs through a 
long space of time, in water-gilding and other manufactures, 
and when it is administered as a medicine. In the former case 
also, the consequences are palsy, and not the common effects* of 
mercury as given in medicine; so that it is possible the mere 
mode of introduction may, in both cases, have effects which do 
not apply to the usual mode, in medicine, of taking it through 
the stomach. With respect to foreign, and particularly French 
opinions as to the use, or rather the danger of arsenic, they are 
expressed with too much violence to command much attention; 
since they are not the result of experience, but of the sound of 
the word; while they are but in conformity to that somewhat 
partv feeling, which, in finding that mercury also is misused by 

2S 



218 CURE OF 

English physicians, sees no medium, and passes on this valua- 
ble medicine an almost universal condemnation. 

I must here, now, not forget to add, that in France, great praise 
has lately been given to a combination of opium and antimony, 
(laudanum and antimonial wine) given in moderate doses, and 
in the manner of bark, through the intermission: but I have 
had no experience of it, and cannot find that it has been adopted 
in our own country, so as to admit of any deductions as to its 
utility or effects. 

Such is all that I think it requisite to say respecting the reme- 
dies of intermittent, as far as they consist in medicines. But I 
must still inquire respecting other remedies that have been used 
or recommended, whether for their good or evil effects. 

The cold bath has been tried, and I have little doubt that it 
might succeed, and has succeeded, under the same circumstances 
in which charms, or any sudden impression made, whether 
on the mind or the body, are successful. But, to this, its utili- 
ty must be limited; unless indeed it might operate, if persevered 
in for some time, upon the chronic disease, in the same manner 
as any great change of habits does. Having no experience 
however, I can only point out thus its possible effects; leaving 
to practical physicians to consider the obvious cautions required 
in adopting such a remedy. I can equally suppose that the hot 
or the vapour bath might prove a remedy, if administered before 
the paroxysm, on a principle analogous to that which renders 
brandy and opium useful; and thus in fact has it proved one, al- 
though I cannot find many records of trials on this principle. 
But as far as my own observation has gone, it is pernicious in 
the chronic disease; aggravating the relapse itself, and producing 
a tendency to more frequent and more severe recurrences. That 
this should be its effect, might be also anticipated, from the fact 
that the same consequences follow from the use of any remedies 
that induce debility, as from all debilitating actions, be these 
what they may. If the administration can be so regulated as 
not to produce that effect, it is easy to modify this reasoning. 

1 have already said so much respecting the use and abuse of 
mercury when treating of the chronic remittent, that I need not 
go over that ground again; since the remarks apply equally to 
intermittents, with such modifications as must be left to the judg- 
ment of the practitioner in each case, and on which it would be 
endless to give minute rules. The general principles must be 
adverted to; and they are, that it may be useful by removing 
glandular affections, or by producing a new habit, in the chro- 
nic cases, or a new disease, in the acute ones; and reversely, that 
it will be pernicious by inducing debility, or by operating in a 
manner that we cannot definitely understand, on the nervous 
system, so as to increase that, which, for want of a real expla- 



INTERMITTENT. . 219 

natory term, we must call by the customary and vague one, its 
irritability. That mercury does, even in a healthy subject, pro- 
duce a high degree of both these effects, is familiar; and it is 
therefore easy to see how it may prove the pernicious medicine 
in this case, which ample experience has shown it often to be. 

The remarks which I have made on purging, have also been 
chiefly anticipated; as I have further explained, in the same place, 
the different actions, or powers for evil, of the different classes 
of these medicines. All this applies to every form of the inter- 
mittent; and with the same distinctions as to the simple or new, 
and the relapsing or chronic disease. In the former, and under 
circumstances in the variety of the disease, or in the constitution 
or condition of the patient, or in the accessary symptoms, the 
nature of which it would be superfluous to explain, since they 
belong to general and well-known principles in physic, purging 
may often be positively useful; as, to maintain the regular action 
of the bowels, is always indispensable. But in the chronic varie- 
ties, and in these, in proportion to their duration and the debility 
of the patient, while it is not less indispensable to maintain the 
bowels in a natural state, actual purging is almost invariably per- 
nicious, unless applied to for accidental and specific purposes, of 
which every physician can judge. The common, the very com- 
mon effect of it, is to cause relapses or returns of a disorder that 
has ceased, and thus to render chronic a case that might have 
terminated; and when what are called courses of purging medi- 
cines have been resorted to, whether from any theory of their 
utility, or from a mistaken view of the symptoms and their 
cause, it is not unusual to see produced, the most inveterate cases 
of chronic intermittent, and very generally also to find them 
under some anomalous form that might never else have occurred. 

It is for this reason that I may be pardoned for urging this 
subject again, and the more particularly as it applies equally to 
all the cases of chronic Neuralgia under its endless modifications. 
In some of these, as in some of the anomalous intermittents that 
have been already described, there are symptoms, or cases, in 
which purging is reputed to be the true or the sole remedy; such 
disorders being viewed as of an independent nature, or as de- 
pending on sonic imaginary, or even real, causes of their own; 
the possibility or probability of their arising from intermittent, 
or being modes of intermittent, being overlooked or unknown. 
And while this practice is thus esteemed, it has also, within a 
few years, become a fashion in England; or has acquired the re- 
putation of an almost universal remedy, from writings and causes 
to which I formerly alluded, and with the usual pernicious con- 
sequences which attend every active system of practice thus ren- 
dered fashionable and thus empirically adopted. And also, that 
it is not merely a fashion, but, one peculiar to ourselves, thev 



220 CURE OF 

know full well who know the state of continental practice, and 
the horror felt by French physicians in particular respecting it, 
and against us; though, as usual in all such cases, the system of 
France runs to a pernicious extreme in the opposite way. 

It is not within my limits to note all the evil consequences 
daily produced by this thoughtless and almost universal prac- 
tice; since the history of its abuses would in themselves make a 
volume. But, be these what they may, it is not physicians who 
are now to bear all the blame, whatever share they may amply 
merit; since, while in our day of universal pretensions to know- 
ledge, it is the fashion for every one to suppose himself a phy- 
sician, at least in his own case, according to a vulgar proverb, 
this is also the class of medicines which every one thinks he can 
administer with safety and advantage. With us, it might be 
imagined that " calomel and salts' 7 were not merely matters as 
simple to understand and as intelligible in their effects as arti- 
cles of diet, but that they were almost necessary articles of diet 
themselves; nor is it ever imagined that they can do harm, any 
more than it is ever asked by these persons, whether self-em- 
pirics or trading ones, what the nature or causes of the disor- 
ders to which this universal remedy is applied may be, or what 
the circumstances or constitution of the patient. If the united 
ignorance and presumption of self-empirics could ever find an 
excuse, they might indeed claim it in this case; when they see 
practitioners of high fame, if notoriety be fame, following simi- 
lar universal systems of cure, applying salts or "the blue pill" 
to every disorder or symptom in the nosology, and without in- 
quiry; and thus, while saving themselves all the trouble of think- 
ing, rendering physic an art which may be practised by any one 
without previous study or present observation; since the Alka- 
hest does all. 

If it is strong language, it is scarcely exaggerated to say, 
that this universal tampering with salts and calomel is one 
of the greatest misfortunes which fashion and folly united ever 
entailed on England; while it is even matter for satirists, to find 
that a course of the waters of Cheltenham or Lemington, at 
once powerful and precarious, a system of active practice which 
can never be neutral, and which if not useful must be pernicious, 
is held a fashionable necessity, a mode of passing time, equiva- 
lent to any other expensive system of idleness on which society 
has stamped a certain reputation. But this is a small portion 
indeed of the evil, when we review the whole of this most extra- 
ordinary fashion, in a manner, however, in which I cannot under- 
take to examine it here. Whether the old Roman practice of eme- 
tics was more or less pernicious than that of the dinner-pills or 
the morning salts, it is not here my business to inquire; but he 
is widely mistaken who imagines that the injury produced by 



INTERMITTENT. 221 

frequent or habitual gluttony is to be repaired by the further in- 
jury resulting from frequent or habitual purgatives. 

And how far the health of families is preserved, or the rising 
generation, (to use a vulgar term,) rendered vigorous in conse- 
quence of the maternal medicine-chest or the daily visits of the 
apothecary, is amply evinced by the fact, that, in such fami- 
lies, and in such individuals, and often through a long life, sound 
health is as unknown, as a state of perpetual disease is common; 
while, with the usual inconsequential reasoning of vulgar obser- 
vers, the diseases are supposed to demand that practice which' is 
in itself, the very cause of them. Let any family, or any indi- 
vidual thus educated on purgatives, (provided indeed that the 
health is not utterly ruined,) take but courage enough to destroy 
the medicine-chest and lock the door against the physician, and 
they will soon find which was the cause and which the conse- 
quence. 

And in spite of the wide prevalence of these opinions and this 
practice among physicians themselves, I can fearlessly appeal to 
hundreds, who will confirm by their own experience, that in 
innumerable cases of what are called nervous diseases, in ill 
health under endless forms, it is sufficient for the cure, simply 
to abandon the system of purgatives, and leave the patient to 
what is called nature; while this is very generally the real cause 
of the advantages derived from the adoption of a different class 
of remedies, inactive in themselves, but serving to amuse the 
patient while they become substitutes for what was pernicious. 
This also is the very frequent cause of the advantages of tra- 
velling; the effect of which, in such cases, is to suspend this 
destructive practice, and, very often, by simply abandoning the 
practitioner and the system under which it had been established. 
It would be easy to illustrate all that I have here said, by facts 
and cases without end; but there is no observing physician who 
cannot produce abundance from his own experience, while to 
the opposite class such demonstrations would be useless. One 
however I may name, a single case out of hundreds; because it 
is an instance of what I must here notice through a few para- 
graphs more, namely, the effects of this practice in producing 
what are called nervous diseases. The patient was a single lady 
of thirty, of a vigorous and healthy family, and to all appear- 
ance of an originally vigorous constitution, without organic af- 
fections, and who had never known any real disease beyond the 
usual disorders of infancy, in their most slender forms. Every 
nervous affection enumerated in Whytt's formidable catalogue, 
had been however her torment almost from childhood; and on 
making that inquiry respecting her own practice which expe- 
rience has taught me to place among the first, the answer was, 
that she had taken salts or calomel almost everv day since she 



222 CURE OF 

was eight years of age, and was surprised -that she should still 
be ill, and not in the least degree better. 

Such, in reality, are the common effects of this system, even 
in sound constitutions, or where no real disease is present; and 
though other practices, which I shall hereafter have occasion to 
examine, have their share, I believe that this universal use of 
purgatives is the leading cause of the nervous disorders so pre- 
valent in England, and which are obviously increasing every 
day. I admit all that must be granted to want of occupation, 
idleness, or luxury, as also to imagination and peculiar modes of 
life which I need not specify; since all these are unquestionably 
highly efficient in this manner. And while I admit also, so 
must I here notice, as perhaps the greatest and most general 
cause of nervous affections, particularly in men, a state of things 
which seems to have been very much overlooked by those phy- 
sicians who have speculated on this subject. I allude to the 
great increase of mental employment, or of study and business, 
or occupation, requiring mental rather than bodily exertion, 
connected often also with that which frequently becomes a spe- 
cies of disease in itself, education, or study and talents, and the 
latter habitually exerted; added often to confinement' and all its 
collateral evils, and further, too often accompanied by that anxi- 
ety, with its occasional attendants or sequels, disappointment, 
which is the produce of the especial ambition, either as to wealth, 
or honours, or fame, which denotes the present times. This it 
is which peculiarly distinguishes our own age from preceding 
ones, and one class of society from another; which distinguishes 
very particularly the better and the best ranks of the present 
day, from the ignorant, idle, hunting and fighting feudal animal 
once called a Baron or a Knight, and the equally intellectual 
and occupied retainers who, with less wealth, were of equal use 
to society. 

But all this is inadequate to explain the prevalence and in- 
crease of these disorders, including what is called dyspepsia; 
while, if an observant practitioner will easily trace cases innu- 
merable to the very cause that I have here assigned, he can be 
at no loss in explaining, on the principles of physic, why ha- 
bitual purging should produce these effects on the constitution. 
That general irritability is often the result of even a single dose 
of calomel, or of salts, and, in some persons, very particularly of 
the latter, is notorious; but I must not here engage in the patho- 
logy of a subject that would inconveniently prolong this neces- 
sary digression. 

It is easy to see how it will assist in explaining the peculiarly 
pernicious effects of purging in chronic intermittents, and, very 
particularly, the injurious consequences produced by courses of 
purging, or the habitual use of such remedies, in those cases 



INTERMITTENT. 223 

where the presence of local or anomalous symptoms mislead the 
practitioner as to the real nature of the disorder. This is what 
happens when such a disease has the character of dyspepsia, or 
hysteria, or is such as, in any of the modes already described, to 
mislead a routine practitioner. And the reasons are plain, how- 
ever obscure the immediate or proximate cause may be. As I 
shall hereafter more distinctly show, the condition of the ner- 
vous system in such disorders, is one of great debility and irri- 
tability, (to use such vague terms for want of better) or it is 
analogous to that which purging, and also injudicious blood- 
letting produces. Hence it is apparent that such misapplied 
practice is to cause injury, not merely of an incidental nature, 
but directly and absolute^, by adding to the immediate cause, 
or by aggravating that primary morbid state of the nervous sys- 
tem which is the origin of all the evil. 

Thus also, while the abuse of purgatives so often increases or 
even produces dyspepsia, does its effect here illustrate its inju- 
rious action in chronic intermittents. That this is often sufficient 
to produce the former disorder in a sound person, is well known 
to every observing physician; and how often it aggravates what 
it is adopted to remove, is perhaps still better known, at least to 
the class of physicians to which I allude. I mean by this term, 
the true and pure dyspepsia, depending solely on the deranged 
health of the stomach and bowels, as nervous or highly sensible 
organs; the nature as well as existence of which is unquestion- 
able when it is produced by causes purely mental, or by derange- 
ments of the great cerebral or general system. Unfortunately 
for the unhappy patients, a recent fashion has referred all, or 
almost all, these cases, to organic derangements, or, generally 
and vaguely, to what are called the chylopoietic viscera; a con- 
venient phraseology for evading all reasoning: as that fashion 
which this improved theory has almost superseded, had assigned 
them all to the liver, engendering the fashionable term bilious, 
which has, in itself, cost thousands all their comfort and health, 
and not a few their lives; since, while the false theory gave rise 
to the system of mercury as well as purging, it was the effect of 
the former remedy as of the latter, by its action on the nervous 
system, to aggravate, or even to produce, the very disorders 
which it was meant to cure. 

I must next inquire respecting the effects of blood-letting in 
the intermittent, since I cannot well pass it entirely over in this 
place; while it will be better to reserve the full examination of 
this remedy till I have treated of the Neuralgias, as its abuses 
concern chiefly some of the local diseases depending on this 
great leading cause. As to the enumeration which has just pre- 
ceded, its uses or abuses concern also chiefly the anomalous 
cases: while, respecting those, I have already noticed, if not suf- 



224 CURE OF 

ficiently, the evil consequences which it produces in paralytic 
cases, and in the painful affections, be they rheumatisms or what 
not, which are so generally mistaken for active inflammation. 

Supposing the intermittent to be a new disease, of a simple 
character, the propriety, or at least the safety, of blood-letting 
may be argued in the same manner as in the case of remittent. 
Once administered, no evil effects are to be expected from it, 
particularly in a vigorous subject; while it may even be bene- 
ficial, by reducing the force of the subsequent paroxysms. Be- 
sides this, it is sometimes one of the effects of this remedy to 
change the type of the fever; and thus it may convert an inde- 
finite or obscure disorder, such as a double quotidian, into one of 
a more regular form, or, as I formerly observed, cause a remit- 
tent to intermit. 

But it is rarely innocent, and probably never advantageous, 
when repeated, unless indeed some other disease, of an inflam- 
matory nature, should be accidently united to the fever; while, 
when the case has proceeded for any time, and, still more, when 
truly chronic, it is decidedly, and sometimes very highly, inju- 
rious. It is, therefore, like purging, cautiously to be avoided 
in all the chronic intermittent. I have already, when describing 
the chronic remittent, shown how it produces palsy, or converts 
a partial and temporary affection of this nature into a more ge- 
neral and fixed one; as I have also noticed its mischievous ef- 
fects in the apoplectic attack: and as these remarks apply equally 
to all the forms of intermittent, I need not here dwell on them. 
With respect to such collateral or anomalous symptoms as, from 
their painful nature, might be judged inflammatory, and there- 
fore as demanding blood-letting, it is the practitioner's duty to 
see that they do not belong to some of the cases already de- 
scribed, or else to the local derangements of nerves which rank 
under Neuralgia. 

It is here, as in truth in all other diseases, that it becomes re- 
quisite to study the disorder, to ascertain its causes, connexion, 
or analogies: for this it is, and not a knowledge of remedies, 
which constitutes knowledge in physic, and makes the physi- 
cian. Our means of cure are few, if our medicines are numerous; 
the methods of administering them may be learned in a day; 
and if we do not know, philosophically and truly, how they act 
on disorders, their obvious actions towards removing disease are 
as limited as they are generally plain to the senses. This is the 
physic that all can learn without study, and even without intel- 
lect; but this is not the science of the real physician. To him, 
the philosopher in his art, names and terms are matters of indif- 
ference, and symptoms, disorders, are but indications or evi- 
dences of derangements, or of causes of derangement, which 
form his object of inquiry, and by the knowledge of which he 



INTERMITTENT. 225 

becomes all that a physician can be; since, this once ascertained, 
the means of cure follow as a matter of course. 

This question, blood-letting, is so serious a one, not "less as it 
regards remittent than intermittent, that it is not easy to quit it, 
even when it appears exhausted; while having been rendered 
supremely intricate by the variety of opinion and the strength 
of assertion on opposite sides, it would, in reality, almost de- 
mand a length of criticism and investigation which it is impos- 
sible to bestow on it in an essay of this nature. But the more 
we read and compare, the more we come to the general conclu- 
sion, that in these contests, writers have been often referring to 
diseases, in reality, different; that is, essentially different in their 
symptoms or characters, though intrinsically the same, and in- 
evitably designated by one term. It is, again, the question of 
the special cases, of which all physic practically consists; and 
often, of specially universal or epidemic cases, no less than of 
specially single ones. Hence, the perplexity arising from gene- 
ral rules is not less than the thoughtlessness or folly which 
would attempt to la}^ them down; while far too frequently, they 
have been the result of a predetermination and a theory, rather 
than of judicious and careful observation. 

The differences in fevers, whether in single cases or in epi- 
demics, or in seasons or climates, are enormous, as has more 
than once been shown; and as far as this remedy is required or 
concerned, these differences consist in local inflammations. 
Where such affections are ascertained, why should I repeat that 
there alone can bleeding be proper? while I am sure that I have 
the majority of sound and careful observers on my side, when I 
say, that even here, this remedy is not applicable except when 
the pulse is violent and the headach severe, or when severe 
pains indicate material local injury within the abdomen; that it 
is never of use except in the early stages of the disease, and is 
totally inapplicable, unless in very peculiar instances, in certain 
climates and epidemics, and invariably so in old or long stand- 
ing cases; that it is not to be used but in the hot fit, that if re- 
sorted to in the intermission it does not prevent the following 
paroxysm from being as severe, and that it frequently kills the 
patient. 

If, for these opinions, I could quote numerous authors of great 
experience and cool judgment, I shall content myself with 
Clarke and Lind; though to them I might, what is remarkable, 
add a very great number of the French theorists who consider that 
gastro-enteritis is the very cause of the disease. The former 
practitioner condemns bleeding, even in the remittents of hot 
climates, unless inflammation be absolutely present; pointing 
out, further, the greater hazard which follows its use in autumn, 
and in towns and hospitals; while Lind equally speaks of the 

09 



226 



CURE OF 



danger of resorting to it in the fevers of Bengal. Even Sy- 
denham, whose extreme affection for this remedy is sufficiently 
notorious, confesses that it is a dangerous expedient, and often 
protracts the fever to double the time which it would otherwise 
have lasted. 

The next question concerned in the remedies of intermittent 
relates to diet, under which I may include wine; and as I have 
noticed this last in as far as it is a positive medicine in the acute 
or new disease, when speaking of remittent, the remarks on it 
which follow apply chiefly to the chronic form. 

Supposing the disease in existence, cases may be conceived 
where restrictions as to diet and wine may be necessary; and 
these can be determined from the general principles already laid 
down respecting blood-letting or other debilitating proceedings. 

But in its progress, and still more decidedly when it has as- 
sumed the chronic form, a good diet, together with wine as 
a part of this, become necessary, and may even be enumerated 
among the means of cure; while the reverse practice, or low 
diet and abstinence, are found to aggravate it, or to render ha- 
bitual and inveterate a disorder that might otherwise have ter- 
minated. This is a conclusion which might have been drawn 
a priori from the theory of the diseases and from the analo- 
gous evil consequences which follow all other debilitating prac- 
tices. 

It is not less the conclusion from experience, drawn in Italy 
and in France; while, remarkably enough, in the latter country 
especially, notwithstanding the prevalent theory to which I just 
alluded, of the existence of gastro-enteritis as the cause of even 
the chronic and ever-during fever which torments the inhabi- 
tants of its pernicious districts from the cradle to the grave, this 
very condition is attributed mainly to a bad diet and a poverty 
so great as not to be able to command wine; as these also are 
pointed out for the best means of cure, as of security from re- 
lapses. I could not well give a stronger proof of the little va- 
lue of such a theory, when it is one that experience thus con- 
tradicts, nor much better arguments in favour of any practice, 
than that it is adopted by those whose theory it opposes. Such 
also is my own experience; and yet, sometimes from a recent 
fashion, at others from false views of the nature of these cases, 
nothing is more common among ourselves, than to find the most 
rigid restrictions on both these subjects; and even low diet with 
water, recently also with the addition of frequent small blood- 
lettings, recommended as the only cure. 

With respect to wine or spirituous liquors, I must here, how- 
ever add a remark which could not well have found a place else- 
where, and which yet does not properly relate to the subject of 
diet, When used in the chronic disearses so as to produce in- 



INTERMITTENT. 227 

toxication, they sometimes remove the disorder suddenly, at 
least for a time; and in some cases they may thus remove it ne- 
ver to return, or produce a real cure. Hence this practice has 
acquired a certain celebrity among the common people; though 
frequently misapplied, and chiefly from confounding the new 
disease, in which it acts in the manner formerly explained, with 
the chronic one in which it is infinitely less effectual, and not 
unfrequently injurious. If, however, it does cure in such cases, 
the effect is analogous to that which results from any other vio- 
lent and sudden action on the body, or from the production of 
some other and temporary disease; and therefore it is most like- 
ly to be valuable in those who are habitually abstinent or sober. 
If it does harm, as is most frequent, it is from inducing debilit}^; 
and thus will it be most mischievous by repetition, if it fails to 
cure. Thus we can easily judge of the degree to which wine 
may be allowed as an article of diet, and of the restrictions to 
which a patient labouring under chronic intermittent ought to 
be subjected. 

It is probable that in the simple chronic intermittent, little 
evil actually arises on the average, from the direct prescription 
of low diet and abstinence from wine; and chiefly perhaps be- 
cause such patients become weary of physicians, and weary 
equally of medicines and restraint. It is in the anomalous cases 
chiefly that this happens; and especially when the disorder is 
mistaken for some of those already described, for which low 
diet is esteemed necessary, and wine hurtful. Thus, for exam- 
ple, in the intermittent rheumatism of the intercostal muscles, 
such practice, persisted in from the notion of its being pleurisy 
or phthisis, while it would be followed on account of the reputed 
characters of such disorders, would be injurious, as tending to 
perpetuate the disease. And not only in this, but in all simi- 
larly mistaken cases, it is the effect of such a system, not mere- 
ly to perpetuate the original symptoms against which it was 
adopted, but to induce other bad effects, and chiefly that debili- 
ty and those trains of nervous disorders which any debilitating 
practice is found to cause. And further, it in the chronic and 
obscure disorders of this class, such a direct and continuous ef- 
fect is produced, it is also the result of such a system oi diet to 
induce a tendency to relapse*, or to render a susceptible patient 
still more susceptible of the action of the exciting causes; just 
as similar treatment, or a diet habitually poor, renders the heal- 
thy peculiarly exposed to the diseases of Malaria. 

This is the verv French and Italian experience to which I 
have just referred, whether as it relates to the continuance or the 
reproduction of this disease, or of the several endemics pro- 
duced by Malaria, or else as to the susceptibility of new diseases 
by those who have not been formerly affected. And such, in 



Z28 CURE OF 






these countries, is the extent of that experience, so ample also 
the demonstration of the nature of the disorder or disorders, 
that no reply can he made to what I have here been recommend- 
ing; unless it were to assert that England does not possess those 
disorders, and that every thing which I have, in this essay, been 
attempting to demonstrate, is a pure dream. 

To show, now, specifically, under how many forms of dis- 
ease depending on this cause, low diet may be pernicious, would 
be to repeat what has been said before. In this case, as in that 
of blood-letting or purging, it is the knowledge of the disorder 
which must be inculcated; and as, when that is known, the treat- 
ment follows of course, the duty of a writer as to the methods 
of cure is nearly finished, if he has been successful in pointing 
out. the method of distinguishing the disorder. But if I have 
taken occasion to indicate the influence of system, of fashion it 
may truly be called, as to certain remedies or medicines, it will 
not be useless to point out the existence among ourselves of a 
similar fashion respecting diet and wine. If it is partly digres- 
sive, it is not a pure digression: since being a blind practice, as 
it is an extensive and an increasing one, it possesses a considera- 
ble influence for evil as to the disorders under review, attri- 
buted as they so often are to causes in which such practice is 
deemed useful or proper. It is a subject however on which I 
must be brief; as to discuss it as it merits, would occupy space 
which I should not be justified in here allotting to it. 

It would be amusing to trace the moral causes connected with 
this modern revolution of opinions, but it would lead me fur- 
ther than I dare now venture. As the fashion now stands, and 
taking the theory in its most perfect form, it is somewhat com- 
plex, but is comprised chiefly in the following laws; that all 
persons, at least in the upper classes of society, eat more than is 
necessary, or more than is salutary; that all "cookery, meaning 
by that, refined cookery, as well as all condiments, is pernicious; 
and, to sum the whole, that a large proportion of the diseases 
of mankind is the consequence of too full or too luxurious a 
diet. This is a sober view of opinions not always stated so 
moderately; as there are many physicians who, from causes re- 
specting which I need not inquire, maintain this doctrine in the 
extravagant language of the poets an d the satirists. And, in 
medical practice, the consequence of such opinions is to produce 
an interference with the ordinary diet of societv, in health as 
well as in disease, which is sometimes pernicious, and common- 
ly very useless; not unfrequently as absurd on the part of the 
physician as it is teasing or tormenting to the subjects. 

It would be long to discuss this particular question as it de- 
serves; but a few words may suffice to render the truth of the 
theory at least doubtful. The diet, or the quantity of food con- 



INTERMITTENT. 229 

sumed by the better classes in England, has been most mate- 
rially reduced in our own days from what it was in former 
times; as the very slightest historical and antiquarian know- 
ledge will suffice to prove. With respect to any imagined ex- 
cess in quantity, in any case, it is notorious that the body, Na- 
ture as it is called, possesses the means, however obscure these 
may yet be, of disposing of what is superfluous, without diffi- 
culty and without injury, supposing that the digestive powers 
are not in the first instance offended; or that there is a steady 
remedy, in all animals, provided against superfluity of food. 
For the reverse, on the other hand, there is no remedy: and for 
one case of disease produced by excess of food, it would be 
abundantly easy, even in well-fed Britain, to discover thousands 
of evils, and indeed of absolute diseases, caused by deficiency; 
the main and prevailing evil being premature age and a short- 
ened term of life, as is most obvious in the labouring classes. 
If the upper classes are more durable, both as to youth, or beau- 
ty, which is nearly equivalent, and also as to longevity, on the 
average, than the lower, it is chiefly owing to a better balanced 
proportion between the food and the labour, or, what is the 
same thing, to food exceeding the precise quantity necessary. 

And that the better fed and more opulent classes are the most 
durable and the most free from diseases, is certain, though we 
must take care not to make the quantity of medicine swallowed 
the test of disorders, considering how very much this is matter 
of luxury. Let those who doubt this, see what a soldier, a 
sailor, or a labourer, is at forty, compared with the opulent 
ranks; or what, in the other sex, is an opulent female of thirty 
compared to a woman of that age in the lower classes. And 
this is a fact of some importance in political arithmetic; howe- 
ver the reversionary tables of computation have persisted, from 
very obvious motives, in deriving their conclusions from an ave- 
rage which is no small source of profit; of profit not perhaps 
strictly just, could there be deemed any injustice in commerce, 
in demanding all that will be conceded and taking all that is 
given. 

With respect to refined cookery, it is by no means proved 
that more food is consumed under this system than under a 
plainer one: while it is an uncontroverted principle, that the food, 
be it what it may, which is most grateful, is also the most di- 
gestible; such is the association between the palate and the sto- 
mach, or between the mind and the digestive powers. If it 
were to be made a question of votes, the opinion of France is 
also universal in favour of this view; though one exception may 
be allowed respecting the excessive use of strong solutions of 
gluten, or of meat reduced by cookery to that state; since it 
does frequently offend the stomach, unless mixed, as is the prae- 



230 CURE OF 

tice of France, with a due proportion of bread or other less 
concentrated nutritious matter. And as to condiments, of what- 
ever nature, not only the practice and the instincts of all man- 
kind, even in the savage state, show their utility, but they are 
admitted to be necessary by all rational physicians, whether as 
stimulants, or as increasing that grateful taste which aids the 
digestion of food. It is to be suspected that we must have re- 
course to the ascetic principle once more, operating unsuspected 
on so much of our common conduct through life, for the origin 
of this dogma; a principle, as I have already remarked, which 
has decided that whatever is pleasing is pernicious, and that to 
renounce most especially whatever is most agreeable, is the duty 
of man. 

While T am on this subject of diet, always rendered intricate 
by the interference, a not very unnatural one, of prejudices and 
popular opinions, let me here make one distinction, referred to 
this place when speaking of diet under remittent fever, which, 
obvious as it is, is not always made, even by physicians. It is, 
the difference between digestible food and stimulant food. The 
former exists, in reality, in old meats and game, and, as to cook- 
ery, in that which is roasted; and, as it happens, such food is 
also stimulant, being digestible probably for that very reason. 
The reverse articles of diet, of which chicken may be taken as 
the type, and boiled chicken as the extreme, are least digestible, 
but then also they are least stimulant; whence, in practice, a 
very different rule of diet for those whose stomachs require sti- 
mulus and those to whom that is pernicious, or, in comparing a 
convalescent from fever with a dyspeptic person; whereas in or- 
dinary practice, that distinction is too generally confounded, by 
adopting the general term a weak stomach, and treating all 
weak stomachs with the indigestible substances, fish, veal, and 
chicken. 

Lastly, when it is said that superfluous eating is the cause of 
a large proportion of the diseases of mankind, it is an assertion 
that ought to be proved, by showing what are the disorders thus 
produced. Individual cases of actual and habitual gluttony 
must be excepted, or granted: but these are so rare, that it 
would be difficult to produce them in any number, and, still 
more so, to find cases where they generate decided diseases. I 
need not name the obvious disorders which they are supposed 
to cause, or do produce; since these are notorious, as they are 
limited to one or two: while out of the remainder of that enor- 
mous catalogue by which mankind is tormented or thinned, and 
of which many are supposed or asserted to be produced in this 
manner, by the vulgar, the ignorant, and the satirist, as by those 
who speak vaguely, thinking as vaguely or influenced by habit, 
there is not one that can be really traced to gluttony, far less 



INTERMITTENT. 231 

to simple exceeding in diet; and while, at the same time, the 
real causes of all these are notorious, or well known to physic. 
A critical analysis of this question would be abundantly easy, 
as the proofs could be rendered most satisfactory; but it is one 
in which I must not here indulge. 

Yet the very case before us would, alone, go far to prove how 
little the excess of diet is concerned in producing the mortality, 
or even the diseases of mankind. I have already said that the 
disorders produced by Malaria include more than half of the 
total number prevailing at any moment throughout the world; 
as the deaths caused by this poison amount to half the mortality-, 
or more, of the earth; since writers far less liable to suspicion 
than I probably now am, have stated it as far exceeding two- 
thirds. Here, at least, diet, or rather intemperance, has no in- 
fluence; and indeed so far is this from being the truth, that it is 
insufficiency of food and of "luxury" generally, which is one 
of the great co-operators in this enormous mass of evil. Were 
I to add to this, Plague, Contagious fever, Consumption, Small 
pox, Scarlet fever, all of them, and more, aiding in the great 
catalogue, not merely of mortal diseases, but of diseases nume- 
rically, and all equally independent of intemperance, it would 
be somewhat difficult to see how this popular argument could 
be maintained, except as popular arguments are, in spite of de- 
monstration; while a further analysis, which would be abundant- 
ly easy to make, but which I cannot with propriety state here, 
would leave little indeed to be said on the opposite side. 

To restrain, to torment, and to terrify, have been too much 
the custom of physic and physicians, as they have been that of 
other sects in mankind, of far higher note, valuable engines of 
power as they are: and if this system is carried into much more 
of life, there is nothing which affords a readier handle than diet, 
since the restraint can be made incessant, while the terror and 
torment are most effectual; interfering as they do with our most 
necessary wants, as well as with our ever-repeated pleasures: 
pleasures, which, however, it may be unbecoming to speak of 
them, are denied only by hypocrisy, or overlooked because of 
their frequency and certainty; while the conviction would not 
be difficult or long to any one, under events that many have ex- 
perienced, if it comes not to those for whom the world is a 
storehouse of cookery, and life a life of eating. 

A similar fashion has, and recently also, been introduced 
with respect to the use of wine; and not as an article of inebriety 
or excess, but as a mere branch of diet. I do not use language 
that, has not been seriously used by the more violent theorists 
on this subject, when I say that it is reputed as a pernicious and 
a poisonous substance. It may appear singular that such a fa- 
shion should have arisen, somewhat as in the case of food, just 



232 _ CURE OF 

at the moment when the use of wine in excess had fallen into 
disrepute in England; and that with its gradually diminishing 
consumption, this dogma has even gained ground. Of exceed- 
ings in the use of wine, it is not my business to speak, as I as- 
suredly do not defend those: but even here, it would not be an 
easy matter to point out the disorders which it causes, if we 
omit that gross and incessant intoxication which destroys life ? 
sometimes almost without causing a disease to which we can 
give a name. As to the pernicious effects produced by that mo- 
derate and rational use of wine which does not require to be de- 
fined, there is no physician, however inveterate his prejudice 
may be on this subject, who can demonstrate them, far less any 
definite diseases produced by it; while the whole experience of 
mankind, from the beginning of our knowledge of history, is 
against such an opinion. But while we may argue respecting 
asserted facts by means of general principles or by evidence, it 
is in vain to contest with prejudices, and above all with a pre- 
vailing fashion; wjth opinions originating in temper, love of no- 
toriety, or what not, and disseminated by means of that multi- 
tude which is ever inclined to follow because it cannot lead. 
And if there are tormentors of others, so is there no want of 
self-tormentors, in this as in many other cases; the victims of 
many moral causes which I cannot here discuss, and not seldom 
of that ascetic principle again, w r hieh is instilled into us through 
our whole education, though not perceived in its influences, be- 
cause not known to exist by those who submit to it. 

I have left to the last place that remedy for intermittent which 
is popularly called change of air. Of its efficacy in this disease, 
and chiefly in the chronic variety, there is no question; since in 
the latter, it is often the only remedy; but it is not the less diffi- 
cult to give any rational account of its mode of operation: while 
I could do little more than repeat what I have already said when 
speaking of the cure of remittent. 

We can however easily understand, that where the disease is 
maintained, as it has been produced, by residence in the vicini- 
ty of Malaria, the cure may be effected by simply removing the 
cause, as in that disease: and this is probably the circumstance 
under which it is most generally effectual. And here, as in that 
case, it becomes necessary to inquire strictly respecting the cha- 
racter of the soil or country to which the patient is to be re- 
moved; or, the nature of the territories through or to which he 
may be compelled to travel; and hence, again, the necessity of 
that accurate statistical and geographical knowledge so often cen- 
surably neglected by physicians. 

Independently of such a removal from the original cause of 
the disease, the chronic intermittent, and indeed the disorder 
when of a new character or of short duration, is, like the remit- 



INTERMITTENT. 233 

tent, sometimes cured by simple change of air or place, and 
without regard to any reputedly greater salubrity in the place 
resorted to. And I think that experience shows this to be the 
remedy chiefly to be relied on in inveterately chronic cases, or 
perhaps the only one which is really effectual ; since, in those, 
every thing else seems to fail. If in some, however, one change 
is effectual, it much oftener happens that frequent removals are 
necessary, as formerly observed; or that a relapse produced after 
one remove, must be met by a fresh one. The operation in this 
case seems to be that of breaking the habit of the disease; since 
a chronic intermittent appears most often to be a mere habit, as 
mysterious as are all our habits, whether of disease or health. 

If this be the case, a difference in the quality of the air breath- 
ed, which is what the popular phrase would signify, is not in 
itself the remedy; though respecting this we really are not in a 
capacity to argue at present, since it is most certain that the at- 
mosphere, in different states or places, produces effects on the 
body, of which our present chemistry does not enable us to in- 
vestigate the causes. The lungs, or the organs here concerned, 
to whatever extent, are in reality chemical agents superior in 
discernment or power to those of our laboratories; or the invo- 
luntary and unconscious animal is that chemist which the reason- 
ing one is not; carrying on operations which he can neither 
imitate nor discover, and detecting substances which he cannot 
find. And thus also it is, even with regard to vegetables. If 
chemistry cannot detect that Malaria, or that contagion, before 
which mankind falls as before the thunderbolt, if where, to its 
finest tests, the atmosphere is the same compound, and yet even 
vegetables either thrive or die, there may be far more of which 
it does not yet know, capable of acting powerfully on the body, 
whether for health or disease. Thus does our nicest chemistry 
detect in the atmosphere of London, nothing more than what 
the touch itself discovers equally well, volatilized coal, soot; a 
substance which no knowledge of ours can infer to be a poison 
to vegetables: yet here vegetables refuse to live or cease to 
thrive; losing their powers gradually, or, as London extends, 
retiring to a further circle, as by a slow gradation they lose the 
power of producing fruit, at length to yield up even their lives. 

But while we do not know that the air alone does act thus 
as a remedy for chronic intermittent, and while it is to be pre- 
sumed at least, that change of habits is an efficient cause in the 
cure, it is expedient that, to change of air or place, there should 
be added every other change which can be made as to the former 
mode of life of the patient, whether as to occupation or what not, 
while the modes of effecting this are too obvious to require ex- 
planation. But I will not conclude this part of the modes of 
cure, without repeating what I said on a former occasion, and 

SO 



234 GL T K.E Ot 

what most obviously is one of the very frequent advantages de- 
rived from "change of air." By means of this, a pernicious 
method of practice is broken'up or abandoned; or the disease is 
truly cured by casting off the misapplied remedies and the prac- 
titioner by which it was produced or maintained; as in many 
other cases, where other ill health is the result of tampering with 
medicines, and the effect, purely, of such medicines, it is re- 
moved by simply abandoning their use, while the credit is given 
to the travelling or the change of air. 

It would be more agreeable, if points in medicine, or indeed 
in any other science, could be discussed without collateral cen- 
sure; but it is plain that where there are no grounds for such 
remark, there is nothing to be corrected, or that science has 
attained perfection, and ought therefore no longer to stand in 
need of elucidation and inquiry. To attempt to point out what 
seems better or right, it is necessary to explain what appears bad 
or wrong: and it will scarcely be contended that physic has ar- 
rived at that point of perfection which admits of no corrections; 
while wherever it is imperfect, or erroneous, it being also an art 
administered by men, those who thus administer it must become 
implicated: an appearance of personality being thus conferred on 
remarks which are purely directed against the imperfections of 
the science and the art: imperfections in which we all partake, 
but which it is the duty of each to labour to diminish, for him- 
self as for others. 

If I have thus terminated all that my own and the general 
experience has dictated as to the treatment of chronic intermit- 
tent, I must not however pass over the opinions of Rush, how- 
ever little they may agree with my own experience, and with 
that, I may fearlessly add, of practitioners at large. Yet it is 
impossible to disbelieve a positive assertion on the part of such 
a man, however marked by singularity these have often been: 
and the only solution therefore must be, that the chronic inter- 
mittent of Philadelphia or New York, or perhaps of the United 
States in general, is a different disease from that which bears the 
same name with us. His remedy consisted of blisters applied 
to the wrists, a plan which, according to his statement, was ge- 
nerally successful. When it was otherwise, one or two bleedings 
never failed to remove the disease, while bark was found useless, 

I may now terminate what relates to the remittent and inter- 
mittent fevers, or the first division of the medical part of this 
essay: a discussion which, if it has occupied an unusual space, 
was demanded principally by the view here taken of the ano- 
malous forms of this disease. It is in attempting to establish 
new views, that a writer is condemned to a length of inquiry 
which is easily curtailed when once these have become admitted; 
as it is in working his way through controverted points, that he 



INTERMITTENT. 235 

is compelled to accumulate evidence and arguments. And if, 
while the chief inquiries respecting the cure of these fevers have 
been directed to the obscure and anomalous cases, I have some- 
times omitted to specify to which of these, respectively, the 
remedies, whether for good or evil, apply, the reader will have 
no difficulty in reasoning respecting the use and abuse of any 
mode of cure, when he has once convinced himself of the truth 
of these general views, and learned to discriminate the cases that 
may fall under his notice. A single example from each of the 
two main divisions, will suffice as an illustration of what it must 
really be now useless to detail more particularly or minutely. 

If the case should be a palsy dependent on intermittent, the 
fundamental means of cure will be the same as in the simple 
fever, acute or chronic; or, to shorten the catalogue, it will con- 
sist in bark and in change of air. But in such a local case, we 
are also permitted or called on to use the local or other means 
which are found beneficial in palsy from whatever cause: the 
great caution, or exception, being this, that we avoid what, from 
being hurtful as to the fundamental or real disorder, must also 
be pernicious to this its mode or symptom; while what these 
things are, has been amply shown. 

On the other hand, should the case be an inflammatory one, 
should it for example be of a pleuritic character, the fundamental 
caution, here also, should be the main circumstance in our recol- 
lection; or we must remember that while blood-letting does not 
cure, but aggravate, the original fever, it will also be prejudicial 
to this mode or symptom, exactly under the same circumstances 
and in the same degree. But here also, as in the case of a 
palsy, we are permitted to use such accessary means as are of 
service in diseases of this character, while not prejudicial to the 
fundamental one; while, if I need not specify what these are or 
may be, a distinct example of this nature will shortly come under 
review in treating of the Neuralgic ophthalmia. 



CHAPTER IX. 



Of Neuralgia in General. 



If I have already stated in the introduction to this essay, the 
great number of j r ears which have passed since I considered 
Neuralgia under its best known form of Tic Douloureux, as a 



236 CURE OF 

mode or variety of intermittent, and if I have taken every op- 
portunity in my power, short of a formal treatise, to make that 
opinion known, that it might be effectually investigated, the 
progress which it has made is so limited, and the conviction as 
yet so narrow and so imperfect, if indeed it can be said to exist 
at all, that it will here be necessary to give the grounds on which 
it was formed, in some detail. Should others have adopted the 
same opinion independently, though at present unknown to me, 
I shall be pleased to think that my own is thus confirmed: but 
that this is not a view generally-entertained, is plain from that 
practice, the division of the nerve, still resorted to for the cure 
of other Neuralgias as well as the Tic, or, if abandoned, not re- 
nounced from a juster theory of the disorder, but from experi- 
ence of its inefficiency. And this is not less proved, from the 
vacillations and the variety of the practice, among which I may 
include that of administering narcotics, lately in high repute, 
and from the nature of the treatises on this subject which have 
appeared: while if tonics, and particularly iron, have lately been 
introduced, they are not only of very recent date, unless in soli- 
tary and experimental instances, but are given, rather empiri- 
cally than from any just theory of this disorder, or from any 
view of its connexion with intermittent fever. 

If in enumerating the anomalous forms of intermittent, in the 
preceding part of this essay, I have had to encounter the hazard 
of criticism from arranging under it diseases not generally sup- 
posed to belong to that leading one, I have been in some measure 
borne out by former authors; though in doing this, I have some- 
times placed there a disease which I should have preferred class- 
ing in the present division. Hence, in this one, there will be a 
deficiency arising from that cause: but it will be a small evil to 
be thus deficient, when I foresee what will happen from the at- 
tempt to rank under Neuralgia what I have actually done; dis- 
eases which no one has yet considered as belonging to it, and 
for which I cannot refer to the authorities and opinions which 
supported me in the former case. I must, in fact, consent to 
contend my way nearly through the whole, against inveterate 
habit and against prejudices; probably, often against pride not 
less inveterate: a disagreeable situation, since it demands evi- 
dence and arguments that might otherwise have been spared, 
while these are viewed with a jealous eye, or at least make that 
impression which arguments, and even evidence, ever do against 
prejudice, namely, nothing; and since it inevitably leads to a 
controversial tone of writing, as new opinions cannot be stated 
without contending with those to which they are opposed, nor 
even direct arguments produced without a critical investigation 
of former and contrary ones. 

If I were now> at this stage, to give a list of the disorders 



NEURALGIA, . 237 

which I propose to rank under Neuralgia, or, as is the truth, 
under Intermittent, it would doubtless be the correct and logical 
mode of commencing the subject. It would be that which a 
scientific investigation ought to adopt; as the proofs would then 
also be arranged in such a manner as to establish all the facts in 
the briefest and most regular method. Thus might the preced- 
ing part of this essay, as well as the present, be reduced to a 
smaller space, and thus also would the two have been amalga- 
mated under one general arrangement of species under a genus, 
or varieties under a species. But, to follow this course would 
be to commence by attacking, without preparation, a host of 
prejudices; to attempt to convince him whom we have begun, 
perhaps, by angering This is not good policy; and though the 
proceeding be logical, it is not a logic which gains its ends. 
Therefore have I determined to sacrifice science and brevity to 
convenience; and by a gradual development of the subject, con- 
forming as much as possible to previous opinions, to allow the 
evidence to come forward in the mode in which it is least likely 
to meet with opposition, or to shock those to whom the subject 
is new. Such an explanation was due to a certain class of my 
readers, as well as to myself; as those to whom I allude will ad- 
mit without hesitation. 

I must yet demand permission to make another explanation, 
in defence of a want of order and of correctness of division, 
which, in the present stage of this inquiry, and in the first ge- 
neral treatise on this subject, was not to be avoided, however 
easy to regulate when once the views which it proposes shall 
have been admitted. If it is similar to one I made before, it is 
even more necessary here. 

In the disorders which I am about to enumerate, some have 
been considered as independent diseases, arising from very differ- 
ent causes, while, of these, there are a few which have even es- 
tablished an independent character almost as ancient as physic 
itself. 

Others have been viewed as symptoms of some disorder, but 
not of this one; while others again have been considered as tri- 
vial, or else inexplicable; mysterious cases occurring once in an 
age, and out of the common rules of physic: while, still further, 
a few have been viewed as the produce of external injury; me- 
chanical solutions of continuity or derangements of structure. 
Under such a confusion of names and opinions, I had no re- 
source but to form an entire new arrangement, by creating ap- 
parently new diseases and forming, new terms, or else to abolish 
old and received diseases with their names, treating them as va- 
rieties, or lastly, as least presuming, to treat as Neuralgia, un- 
der their old names, those varieties which were already named, 
and to suffer the others to remain as nameless as thev have hi - 



238 NEURALGIA. 

therto been. And this plan, as the least offensive, I have adop- 
ted; while the inevitable consequence of it is a total want of 
philosophical arrangement, which, in any other science than 
physic, I should have been ashamed to countenance. 

In pursuance of this plan, I shall now therefore commence 
with the Neuralgia of the face, or, as it was once exclusively 
viewed, of the superior maxillary nerve, commonly known by 
the name of Tic douloureux: since this is the variety which has 
attracted most attention, which, not very long ago, was the 
only one supposed to exist, and which, if not the most common, 
has at least been the most discussed; while, if I mistake not, it 
is the one which has especially served to mislead and blind phy- 
sicians respecting the true nature and theory of the. whole of 
the disorders of the nerves connected with intermittent. 

However repugnant to my own views of order, I shall also 
reserve the proofs which I propose to offer respecting the real 
nature and connexions of all these diseases, to a late period of 
this inquiry; because I shall thus at least pave a way for their 
reception in the minds of those who might here have been star- 
tled at any such attempt to change their established and long- 
cherished opinions. I trust indeed that very little in the shape 
of formal proof will be required, after the diseases themselves 
have been described; as the facts will most generally carry their 
own evidence with them. 



CHAPTER X. 



Of the Neuralgia of the Face, or the Tic Douloureux, 

I cannot exactly trace the period at which this disorder first 
began to attract attention in this country, under its present French 
name; but it is not a very distant one, while, as far as I can now 
find, there was nothing written respecting it before the notices 
of Heberden and Fothergill. As far also as I can discover, al- 
though the disease is described under various names, by nosolo- 
gists, according to its several varieties as here brought under re- 
view, the term Tic douloureux seems to have originated about 
the year 1756, with Andre, hereafter mentioned as the surgeon 
who had also first recommended the division of the nerve. The 
public at large very naturally considered it, when first thus 
marked out* as a new disease, and still views it as a rare one. 



TIC DOULOUREUX. 239 

But it is neither new nor rare: it is the term alone that is new y 
while the apparent rarity is the result of two causes. To be 
noticed as a case of this disease, the pain must be excessive, and 
must also be limited to a peculiar part of the face; and further, 
it must be found in the opulent, or in those who, little accusto- 
med or willing to bear pain, fly to physic for relief, and thus 
call attention to themselves and their cases. There are thou- 
sands who suffer from it, under forms less marked; and thou- 
sands, in the middling and lower classes, who endure it, even 
in its worst form, but of whom the public never hears. He 
who will thus seek it out, will soon be convinced of the trufo 
of this assertion, as I have long since been: and though he mar 
find a much greater number of the cases not decidedly marked 
by the strongest and most peculiar features of this disorder, and 
therefore not known by this new popular term, he will be sin- 
gularly unfortunate if he does not also meet many* of the best 
defined and most intense character, generally endured as best 
they may, and seldom forming objects of attention to the great 
mass of practitioners. If in a single and not very extensive 
tract in this country, I have produced, among the labouring 
classes, not less than a hundred cases in the course of a very 
brief investigation, it would be very extraordinary should others 
with the same care, not meet similar success. Thus also a late 
observer finds now that it is very common in India and Persia: 
while, if a suspicion is thus excited that it is in those climates 
connected with the Malaria, or the remittent, as I have ascer- 
tained it to be in the West Indies, there are unfortunately no 
details, as usual, by which this could be justified: such are the 
vexatious consequences which follow from the want of a correct 
theory. 

It is natural to ask how this disorder was designated before 
the present popular term was introduced, or the more scientific 
one, Neuralgia, applied to it. It may not be very easy to an- 
swer this question satisfactorily; but the term rheumatism of 
the face appears to have been, as it is even now, the most com- 
mon name under which it was known. Thus also has it often 
been attributed to disease in the antrum maxillare; an error 
still daily committed: while, in other cases, and under modifi- 
cations, it has been called periodical headach, clavus hystericus, 
and toochach; and, if I mistake not, has not unfrequently also 
been attributed to gout; an error, even now sometimes commit- 
ted. Under how many more excuses for ignorance it may have 
been described or named, it would be difficult to discover, with- 
out more inquiry than the question is worth; but it is easy to 
perceive that it has often been set down as. one of those rare and 
mysterious diseases of which physic can give no account, while. 
by thus sheltering itself, it too often finds excuses for ignorance 



240 TIC DOULOUBEUX. 

and carelessness. And we shall commit no injustice if we at=> 
tribute a large portion of this confusion or error to the nosolo- 
gists: not to quote all of whom, however, I may merely notice 
the confusion of Sauvages on this subject; when, ranking it, not 
•very improperly indeed, among his maladies convulsives, un* 
cier spasms, he associates it with many other irrelative disorders 
besides trismus. 

If the introduction of the term Tic douloureux has had the 
eTect of rendering this disorder far more noticed than it had 
bsen, and has thus appeared to careless reasoners to multiply 
tie cases themselves, it seems to me to have been attended by 
tie countervailing disadvantage of checking the progress of in- 
restigation into its real nature. If it is too generally the effect 
*f terms to become the substitutes for ideas, this is peculiarly 
;rue of physic; if indeed I do not here commit a great injustice 
;n appearing to forget that such, or little better, has been the re- 
puted science of Metaphysics, not merely in the hands of Kant, 
but almost even from Aristotle to our own days. And if this 
is, at least far too much, the character of physic itself, so is it 
most especially true of the mass of practitioners; to whom it is 
that art, that mere trade, which it ever must be, and who, pos- 
sessed of the name of a disease and of the opposed names of 
the medicines with which it is to be fought, concern themselves 
no further than in applying the correlative hostile draughts in 
the quality and number that have been established. To this 
class, to the vast majority, a name is invaluable; for, deprived 
of it, they are helpless; and thus, while a term is their sole guide 
and rule of conduct, in that term are all their reasoning and all 
their philosophy centred. 

And if, in the term Tic douloureux, there was no analogy 
implicated, nothing which could guide an even somewhat supe- 
rior class of practitioners to reason respecting the probable na- 
ture and connexions of this disorder, the original limitation of 
that name to the most painful form of Neuralgia, and to that 
when occupying one particular nerve or spot, added to the sin- 
gular severity of the disease thus partially designated, served 
in some degree to keep' out of sight all its modified forms 
whether as to situation or severity; and thus to entail a conti 
nued blindness on all those who, unable to reason without terms, 
unaccustomed to inquire about things, or unpractised in philoso- 
phical investigations or analogies, were incapable of seeing when 
deprived of their customary guides. The mere substitution of 
the term Neuralgia has here been of great use; by pointing out 
the road to a generalization, of which physicians have neverthe- 
less been most tardy in taking advantage, as I trust to prove be- 
fore long. 

If I could point out many other reasons which seem to have 



Li- 

d 

I 



TIC DOULOUREUX. 241 

acted in blinding physicians as to the true nature of this disease, 
I am unwilling to prolong remarks that cannot be made without 
implying censure: but there is one which I cannot pass over, 
because, while it is a fact of principal importance as concerns 
the cure of this disorder, it is one which has most obviously 
tended to maintain the popular ignorance, as well indeed as the 
general ignorance of practitioners themselves, respecting its na- 
ture; as it is one of the strongest proofs of that, and a bitter one 
indeed to those who have suffered from it. If I were to say 
that those who are accustomed more to the use of the knife, or 
to mechanical operations, for the cure of diseases, than to medi- 
cine, are too apt to view physic rather as a mechanical art than 
a philosophical science, and too ready, almost in a literal sense, 
to cut the knot which a better reasoner would attempt to untie, 
I should perhaps be thought desirous of retorting a censure 
which the operating branch of this profession has, for some time 
past, with no very good taste and as little liberality, bestowed 
on physicians: from that spirit of rivalry in trade, apparently, 
which is the disgrace of this science, if not of others, in our own 
country. But if I desire to avoid an illiberality of comparison 
which cannot fail to be injurious to those from whom it proceeds 
as to those to whom it is applied, (while having, during many 
years of military service, divided my own time equally between 
both branches, and having consequently been taught to esteem 
both, I cannot feel as a partisan on either side,) it is to the prac- 
tice of dividing the affected nerve, or to the inconsiderate and 
misplaced use of the knife, and therefore to surgeons and sur- 
gery, that we must very principally attribute that persistence in 
error respecting this disease which is yet far from overcome: 
while the fact of thus viewing it as a merely local disorder of a 
nerve, unconnected with any general disease of the system, 
speaking little as it does for the observation and reasoning pow- 
ers of those who adopted and persisted in this error, appears to 
have acted in checking the investigation that might otherwise 
have been made into the analogous diseases, by cutting through 
almost literally, with the nerve itself, the very chain of analo- 
gical reasoning. 

But enough of remarks which were however, unavoidable: 
and having thus said all that appeared necessary respecting the 
term Tic Douloureux, I shall in future avoid it as much as pos- 
sible: wishing, for reasons now obvious, that it could be extin- 
guished from the vocabulary of physic. The word Neuralgia has 
the advantage of being general; and it is one which even the 
people will find more manageable by their organs than that 
which they so invariably mutilate. 

Anatomists, with a refinement which is made a matter of 
much exclusive, boast, and of not a little vulvar wonder, have 

31 



242 TIC DOULOUltEUX* 

undertaken to name the precise ramifications of the precis© 
branches of the precise " pairs of nerves" in which the Neural- 
gia of the face must exist; and this petty pride has perhaps not 
had a small share also, in maintaining the ordinary false views 
of the nature of the disease. It may occur in any part of any 
nerve of the face; though thus reputed to occur chiefly or solely 
in the second branch of the fifth pair, and in the portio dura of 
the seventh: and I am almost inclined to blame myself that I 
should even submit to distinguish these particular seats of the 
pain from others, since the disease is the same wherever it hap- 
pens. And not only is this most violent and decided form of it 
found in various parts of the face, but, indifferently, in the head 
also; since in one of the best marked cases of it that I have wit- 
nessed, and where the pain w r as so excessive as to bring on de- 
lirium, it occupied a small point near the insertion of the occi- 
pital muscles. 

I need scarcely say, that, in this disorder as it stands in the 
popular acceptation, the pain is most severe; being probably as 
great, often, as the nervous system can endure: since all the sur- 
rounding objects sometimes disappear before its violence, or it 
deprives the patient of all other sensations; in vulgar language, 
of all his senses; frequently also inducing absolute delirium,, 
as I just noticed; an effect rarely occurring from any other pure 
pain than the inflammation in the bowels. This extremity of 
pain is commonly instantaneous in its attack; resembling very 
much, in this respect, the electrical shock; and most generally 
it is similarly transitory, coming on in repeated fits during the 
continuance of the entire paroxysm. It is not, at the same time, 
always the sole pain; since a general painful state exists through 
the whole paroxysm; sufficiently severe, should it be the only 
one, as it often is, but appearing almost pleasure, when contrasted 
with the more acute shocks of the nerve. 

During this state, the integuments, or rather the whole sur- 
rounding parts, become extremely irritable, or tender to the 
touch; and commonly more so to a gentle contact than to firm 
pressure, which, on the contrary, sometimes removes that con- 
sequence, diminishing the moderate pain of the nerve also: and 
it is often apparent that there is a general increase of vascular 
action in the neighbouring parts, or a species of temporary in- 
flammation, very similar to that of rheumatism; an analogy of 
some value in the history of this disorder. As the pain ceases, 
this general soreness becomes commonly more sensible, remain- 
ing, often, for some time after that has disappeared; when the 
whole vanishes together, leaving the patient in his usual health, 
or rather, most frequently in a state of debility and exhaustion. 

To this general description, which I might have made much 
more striking, even without exaggeration, I need only add, that 



TIC DOULOUREUX. 243 

Xvhen the fit is impending, it is often brought on by any motion 
of the parts, such as, by the act of eating; as, during the course 
of a paroxysm, the same causes often re-excite the acute pain 
when comparatively dormant. 

Such is a simple and ordinary case of a paroxysm of this Neu- 
ralgia; but many accessary circumstances of an equally obvious 
nature sometimes attend it. Thus, the neighbouring muscles, 
and even the more distant ones of the limbs, are often affected 
with spasms, occasionally to a considerable extent: while, not 
unfrequently, with the usual charity of the healthy, they are 
attributed to impatience and debility of mind on the part of the 
patient; as is more especially and certainly the case when these 
spasms seize on the larynx, producing involuntary cries, or con- 
verting the ordinary breathing into audible sounds. In truth, 
no one is entitled to assume the office of critic on a Neuralgic 
patient, who has not been a patient himself; and, for the cause 
of charity, it were perhaps to be wished that the disorder were 
more common, or that a short apprenticeship at least to it, were 
a more general lot. 

Frequently also, there is an increased flow of saliva, and, 
much more often, of tears, which, in some cases, almost stream 
from the eyes; scarcely noticed by the patient, but not so by the 
by-standers, always ready to attribute to mental weakness, what, 
in this case, is a mere increase of secretion from disordered ex- 
citement of the glandular nerves; forming, in fact, a peculiar 
variety or modification of Neuralgia which I shall have occasion 
hereafter to point out more distinctly. And if it is an episodical 
remark, I know not where better I can introduce it than here; 
that in patients who have suffered severely from Neuralgia under 
any of its forms, if the lachrymal glands have once been mate- 
rially affected by the disease, they rarely recover their healthy 
state: and thus, that tears continue to be, not only easily excited 
in those who scarcely knew, before that, what it was to shed one, 
but that they frequently occur, and even in streams, without any 
mental cause at all, and not uncommonly in sleep, though no 
dreams are present, or at the hour of awaking, often lasting a 
considerable time, and producing no small inconvenience. 

Lastly, among the more obvious accompanying symptoms of 
a paroxysm of this Neuralgia, it sometimes happens that other 
and distant nerves become also excited to pain. Where anatomy 
easily traces the connexion, this is scarcely matter of surprise; 
and I shall hereafter show that such cases are not uncommon. 
Where there is no such continuous connexion, we must, I pre- 
sume, suppose that the diseased condition exists in more places 
than one; unless any person is desirous to explain this by the 
very luminous term sympathy. I need not accumulate exam- 
ples; as it will be easy to conjecture what may happen of thifl 



244 TIC DOULOUREUX. 

nature, from one ease, within my knowledge; in which, after 
the pain in the face became established, there came on a similar 
one in each thumb and each great toe, continuing, but with less 
severity than the primary pain, during the paroxysm. 

Now if such is the obvious character of a paroxysm of this 
Neuralgia, the most popular variety, or rather that to which, 
almost alone, the name has, generally, and till very lately, been 
given, there is more, less obvious, which it is the business of 
the physician to notice, and which, had it been duly noticed and 
reasoned on, should long since have explained the true nature 
of the disease. 

Immediately before the attack, if the pulse is examined, it 
will be found to put on that character which it possesses in the 
cold stage of an intermittent; while, through the progress of the 
paroxysm, it passes through the other analogous changes. If 
also a watchful patient, at least when directed to do so by his 
physician, (which I fear has rarely been the case,) attends to his 
previous feelings, he will find that there are most commonly 
some indications of a cold stage, generally obscure, it is true, as 
is the case in most of the anomalous and chronic intermittents, 
but still discernible; while doubtless it may sometimes be want- 
ing or difficult to make out, as is so often the case in such ob- 
scure intermittents. When most distinct, it is like the sensa- 
tion of cold water applied to some part of the face, or trickling 
over it, being indeed often thus described by patients; or there 
may sometimes be a sensation of cold, more general, if also 
transitory. The skin, at least of the face, also becomes pale 
and shrunk, with that peculiar physiognomy attending ague, so 
indicative of all these diseases, if so perpetually overlooked: 
and this is a symptom which, if unnoticed by the patient, ought 
never to escape the eye of an observing physician, explanatory, 
and often useful as it is. Occasionally, this paleness is local in- 
stead of general; and I have seen cases where I could pronounce 
that the paroxysm was threatening, from one side of the face 
turning suddenly white while the other retained its natural as- 
pect and colour. 

If this is the cold stage of this particular intermittent disease, 
the fit of pain appears to belong to the hot one, or thus at least 
has it always seemed in my experience: and if, as a hot stage, 
it is not a very marked febrile state, it is sometimes sufficiently 
apparent, in an increase of heat, local if not general, in the 
change of the pulse, and in a thirst which occasionally accom- 
panies it. And if it is a slightly-marked hot fit, it is not slight- 
er than that which often occurs in chronic intermittent when 
other kinds of local symptoms are present, or even when the 
cases are pure; while in such cases, as well as in this and other 
Neuralgise, the sweating stage is rarely well marked, or is per- 



TIC DOULOUREUX. 245 

haps only discovered by the facility with which that effect is 
produced by exertion. 

Thus I have described a paroxysm of Neuralgia as resem- 
bling that of an obscure or chronic intermittent, with the super- 
addition of its peculiar pain or local affection of a nerve; and it 
remains to see what resemblance the general course of the dis- 
ease bears to the common or simple intermittent, or rather, 
since I am not yet formally discussing the proofs of identity, 
what are the remaining characters of this disease. 

It may be considered that there are two forms of this, as of 
other Neuralgia?, the acute and the chronic; or the disease may 
be new, or habitual; a distinction which it is important to make, 
because the latter is, like all intermittents, far less regular than 
the former, while being perhaps more observed, it has aided m 
misleading physicians respecting the true nature of Neuralgia. 

In the recent state, or in the first case, it returns in distinct 
and defined paroxysms, occupying a certain number of hours, 
or even, in some instances, but a few minutes, and leaving an 
interval of health. Where I have had the best opportunities of 
observing it, the returns are daily, or the type quotidian, while 
they maintain a regularity of period similar to that of common 
intermittent, and subject also to the same variations as to time. 
If I have also met with tertian, and even with quartan periods, 
they have been, in my own experience, more rare: nor, in these 
cases, has the disease been so apparently regular, though I have 
little doubt that the practice of others will here supply my de- 
ficiencies. 

Now when the disease is of long standing, or of a chronic 
character, it is less distinguished by this regularity, and, further, 
as far as I have had opportunities of seeing it, is even more un- 
certain than the analogies, in common or anomalous intermittent, 
with which it is best compared; with the single exception, as 
far as I have seen, of the affection of the heart. Whatever may 
be the causes of this irregularity, if it is not the only fact which 
has aided in misleading physicians respecting the true nature of 
this disease, it is one which will probably cause many to sus- 
pend their judgments upon it at present, or to deny altogether 
the theory which I have here adopted. As an instance of these 
cases, I may quote one from Sauvages, where had it not been 
so durable, and not watched by an attentive physician, no re- 
gularity would have been perhaps suspected. In this, the pain 
occurred but once in eight days, yet never failing, and lasting 
thirty hours; while, being in the temporal muscle, it is called by 
Salius the Hemicrania lunatica. The entire duration extend- 
ed to three years and a half. 

I know not that I am able to explain why it should appear to 
be peculiarly irregular when compared to other chronic inter- 



246 TIC DOULOUREUX. 

mittents; yet if I fail, here or any where else, in elucidating 
difficulties, I must attribute it to a very narrow experience, 
arising from circumstances not worth detailing, and which I have 
vainly attempted to atone for by increased attention, finding lit- 
tle assistance from personal communication or printed records; 
so unsatisfactory are all these, from the fundamental deficiency 
of a system of observation founded on true views of the nature 
of these disorders. 

As the matter stands, however, the first cause of obscurity 
must be sought in the rarity of the highly-marked cases and ri- 
gidly-local affections of this nature, which have secured for 
themselves the name of Tic douloureux. There is consequent- 
ly a small number of cases from which to form an average and 
a judgment; whereas, were I to judge from all the cases of simi- 
lar disorders, differing in violence and differing in place, which 
I intend here to rank under the same disease, I should decide 
that in the mass of neuralgic cases, the regularity was fully as 
great, under any type, as in the most acknowledged chronic in- 
termittents. 

Another ground of erroneous judgment as to this question, 
and which indeed I ought to have named first, has been the want 
of a correct original theory of the disorder; a want which, in 
science universally, is the parent of erroneous and deficient ob- 
servation. In the ague, of whatever type, the most vulgar 
know the theory of this disease, and thus mark its regularity; 
while in this, where it is not known or expected, it is not noted, 
either by patient or physician: and accordingly, I have, in nu- 
merous cases, ascertained that a Neuralgia, before supposed un- 
certain, or never attended to, was found to be perfectly regular, 
as soon as either the patient or the physician had been informed 
that such was the character of the disorder. And it must be 
noted here also, that while a daily attendance on the part of the 
physician will scarcely happen in many cases, even among the 
opulent, while, with the lower classes, that is likely to be very 
casual, it is abundantly easy to conceive how the regular returns 
of a disorder, not previously suspected to be regular, should be 
overlooked. 

There is yet another cause which has prevented the regularity 
of this disorder from heing marked, where it is actually present: 
and it is an important one in some cases, as connected with the 
history and nature of Neuralgia. Even should the nerve be af- 
fected at the habitual period, that affection is not always a fit of 
the violent pain. On the contrary, it may be a very slender 
one, scarcely noticed by a patient used to much greater suffer- 
ing; or it may appear as a toothach, or a headach, or what is 
called a rheumatic pain of the face: and thus, although really a 
paroxysm of the disease, may deceive both patient and physi- 



TIC DOULOUREUX. 247 

cian, and most of all when, as in the cases last enumerated, it 
will admit of some common or vulgar name. Such in fact is 
the character of the Neuralgia, in whatever place situated: and 
the fundamental error here has been founded on that to which I 
formerly alluded, namely, the assigning it a name expressive of 
violent pain, and the separating this particular variety from all 
its analogies and variations. Such are the endless errors pro- 
duced by ill-chosen terms, and by giving to such terms an im- 
proper value. And still further, as I shall hereafter more de- 
cidedly show, as this disease is but a mode of the intermittent, 
it may be exchanged for or replaced by a common paroxysm 
without any local pain: while even that paroxysm may be so 
slight as to attract little notice from any one, and at least of all 
from a patient accustomed to much keener sufferings. 

Last of all, and particularly when of long standing, it be- 
comes, like every other chronic intermittent, a truly irregular 
disease. Thus it may come as a single attack in the midst of 
weeks or months of repose, excited by some occasional cause; 
or it may, in the same way, adopt any modes of irregularity; 
which it is unnecessary to describe again, as it would be merely 
to repeat what I formerly said respecting chronic intermittents 
in their ordinary character. 

Such then is the total character of the common Neuralgia of 
the face: and if I have dwelt on it at some length, this will ren- 
der it less necessary to be minute as to its varieties, or as to 
other Neuralgias; since, the same general account will apply to 
all. Its similarity at least to intermittent, will even now be ap- 
parent, and very decidedly to those varieties which are attend- 
ed by local diseases or symptoms; while the further evidences 
will appear in their due time. And if I might now treat of its 
cure, it will be best to defer this till I have enumerated all the 
other disorders of the same nature; since, with small exceptions, 
the same general rules will apply to all. 

In examining now the varieties of the Neuralgia of the face 
which I am about to notice, or those of other nerves, be their 
apparent characters what they may, or though they should even 
have acquired names as independent diseases, it will save much 
repetition to premise, that,, in every one, the same general 
symptoms or characters are present. The returns are periodical, 
under the same variations and exceptions; there are the same 
indications of a regular febrile paroxysm ; they alternate simi- 
larly with other conditions of the same general nature, or with 
common intermittent; their types are similarly various; and they 
may either be acute or chronic, new diseases or habitual ones. 
Without such testimony, drawn from cases more or less nume- 
rous, I have introduced no disease here; while many are sun- 



248 PERIODICAL HEADACH. 

ported by analogies or collateral evidences, which will be stated 
whenever the necessity for them occurs. 

As naturally connected with the marked Neuralgia of the 
face, I first must notice those disorders of this class which occur 
in the face and the head; reserving however to a distinct place, 
those that are attended by visible and permanent inflammation, 
and those that are accompanied by mechanical injury or de- 
rangement; though this separation, almost inevitable in the pre- 
sent essay, for the reasons formerly stated, proves often a very 
awkward one, particularly in the case of toothach, where I must 
sacrifice the distinction that I might have wished to make, to a 
popular term. 



CHAPTER XI. 



Of the Periodical Headach, and of Vertigo. 

Of all the disorders which I have thought fit to arrange un- 
der the great leading head of intermittent, this at least is one 
respecting which there can be little dispute, well known and 
pointedly defined as it generally is. Yet though it has been con- 
sidered an intermittent disorder, as it in fact, could not fail to 
be, and, further, frequently treated by the same remedies as the 
common intermittent, I cannot perceive that the conviction 
among physicians, respecting its nature or treatment, is by any 
means either general or satisfactory to themselves. Innumera- 
ble cases must have occurred in every physician's experience, 
where these remedies had never been resorted to, and where 
the disease had been abandoned as incurable; and, as insinuated 
in the preface, I could even quote physicians of the highest note, 
who had submitted to it in their own persons for a long life, 
even in its most marked and regular form, the tertian, without 
adopting the obvious plan of cure, and even arguing to the last 
against the present view of its nature. 

If I cannot therefore find that physic has viewed it as a va- 
riety of intermittent fever, whatever may have been the opi- 
nions of individual physicians, still less do I perceive any in- 
clination to consider it as Neuralgia, and, if situation can, for 
the present purpose, be allowed to establish a leading distinction, 
as one of the varieties of ihe Neuralgia of the face, Such how- 



JPERTODTHAT. HEADACH. 249 

ever is the view that I propose to take of it; while from its 
greater simplicity and regularity, and its more apparent con- 
nexion with simple intermittent, it forms that connecting link 
between this leading disorder and the more painful Neuralgia, 
or Tic, which aids in proving the true nature of this formerly 
obscure affection. And being without that strongly-marked 
symptom, the excruciating pain, which, by attracting the chief 
or sole attention of common observers, has misled them so long, 
it is more likely to be received as a mode of anomalous or local 
intermittent, and, as such, to command an assent which will 
probably yet for a long time be withheld as to the Tic doulou- 
reux. 

As it appears to me that the proofs of this identity, a triple 
identity, as 1 may call it, will be developed, partly in the his- 
tory of this disorder, and partly in the course of a further exa- 
mination as to all the Neuralgia?, I shall commence by describing 
the disorder itself. And this I must do at some length; because 
it is by attending to varieties and anomalies rather than to pure 
and well-marked cases, that we discover those evidences of con- 
nexion among what have been considered defined and separate 
disorders, which serve to mark their identity. 

The periodical headach may possess any of the types of in- 
termittent; and if I have not myself seen it under every form, 
I have at least known it as a double quotidian, as a single one, 
and as a tertian. Whether if it existed as a double tertian, it 
could be distinguished as such, I cannot foresee; and if it is 
ever of a quartan type, I cannot at this moment discover that, 
from any recollections or references. My learned medical read- 
ers will probably be able to supply this and many other defi- 
ciencies: the produce, sometimes of pure ignorance or narrow 
experience, at others of a desire to avoid tediousness or super- 
fluity. 

I have never said that all the disorders which I have here 
collected under the head of intermittent, do, and must of ne- 
cessity, arise from Malaria, though I have tried to prove that 
this poison is often present where it is not suspected. We are 
certain only that it is by far the most frequent cause of them: 
yet, if it is possible, it is by no means proved, on the other 
hand, that simple intermittent can be produced, as a new disease, 
by any other cause, though, as an habitual one, it is re-excited 
by many. But when we descend from the simple disease along 
the scale of varieties, or as the local affections of the nerves be- 
gin to predominate far above the general one, I am so far from 
thinking Malaria essential to the production of intermittent, or, 
£o speak specially of Neuralgia, that I have made a particular 
division where it is demonstrably produced, as far at lea! 



^50 PERIODICAL HEADACH. 

we can demonstrate an exclusive cause, even by mechanical in- 
juries. 

I must not therefore be here understood to say that periodi- 
cal headach is necessarily or exclusively the result of Malaria, 
or that, being a variety of intermittent in its symptoms, and 
cured by the same remedies, it is invariably produced by the 
same causes; however frequently this may be the fact, as in 
Spain, where the Migrania is endemic in all marshy situations 
thoughout the country. But were it even demonstrated that it 
can be produced by other causes, this cannot affect the theory of 
the diseases, as it concerns their common or generic nature, 
which I am attempting to establish. The action of Malaria is 
on the nervous system, on the whole and on the parts: or affect- 
ing the whole in a slender manner, it may exert its chief influ- 
ence on some peculiar nerve or portion of a nerve. And till 
we know more of their nature and of this action, we cannot 
pronounce a negative, or say that no cause but Malaria shall pro- 
duce even a simple intermittent: while, if mechanical injury of 
a nerve can produce a partial one, there may be many other 
causes, unknown to us, capable of generating a periodical head- 
ach. 

Be this as it may, it will be found that this disorder is most 
common in situations of the unhealthy nature formerly de- 
scribed, and that it is often directly brought on by the causes 
which produce ordinary intermittent. But what affords a much 
stronger proof of its identity, is the fact that it occurs frequent- 
ly, perhaps most frequently, in those who labour under chronic 
intermittents or remittents, or have formerly suffered from those 
disorders. Thus it may occupy the whole period of one re- 
lapse, as the substitute of what would otherwise have been a 
common one: as it is even found to do, in frequent interchanges, 
and through a long life, in those who possess that inveterate ha- 
bit of intermittent which may almost fairly be esteemed incu- 
rable. Still more remarkably, it is sometimes found to inter- 
change by paroxysms with the common intermittent; or the or- 
dinary fever of one day is replaced, on another, by the headach. 
Thus have I seen the headach and the ague-fit occupying the al- 
ternate days, a modification which may be considered as a dou- 
ble tertian, and proceeding thus through a long period; while 
the same species of combination has also occurred to me under 
the tertian type. Where the chronic intermittent, however, 
has been of long duration, it is more common for the periodical 
headach which is united with it to recur in a very irregular 
manner, as is true generally of the disorder in all its modes, 
when of such standing: and it is in these cases especially, that 
its real nature is so commonly mistaken; as it then wants those 



PERIODICAL HEADACH. 251 

^obvious characters which alone would arrest the attention of a 
superficial observer. 

A headach will not therefore be necessarily removed from 
this division, though it should want its most discriminating cha- 
racters: though it must be admitted, that where this affection 
can arise from so many causes, and put on so many different 
forms, it will often require great attention and acuteness on the 
part of the physician, to discover that a disorder of this nature 
belongs to the division under review. On this I shall hereafter 
have occasion to speak more fully: but I must still add here, 
that if I have not stated all the causes which may render that 
which is truly a headach of this nature, not such in appearance, 
or not easily discernible as such by careless observers or mecha- 
nical practitioners, it is because I have, on former occasions, ex- 
plained the various circumstances under which intermittents, 
whether simple or anomalous, become obscure, from the irre- 
gularity of their periods and paroxysms, and that it would be 
mere repetition to do this again. And not only here, but here- 
after, if I do not explain why the various Neuralgias are so of- 
ten irregular, so irregular as to afford argument to the opponents 
of these views, it is because I presume that what I have already 
said in explanation of this fact generally, will be applied, as I in- 
tend it should, by those who have attended to the former parts of 
this essay. 

It might now be anticipated that the periodical headach should 
exist under the acute and chronic form both, or that it may be a 
new disease or an habitual one. It may be, and is often, a truly 
new or acute disease, or it is the first effect of its cause; though 
it will also appear to be such to those who do not know it as a 
mode of intermittent, when it succeeds, for the first time, to 
this in its ordinary form. How often it is transitory, or of short 
duration, whether from a natural cure or from the use of reme- 
dies, it is difficult to discover; as it either does not attract much 
attention, unless peculiarly violent, or is not recorded, unless 
when it becomes inveterate and chronic. It is in this state that 
it becomes the especial object of notice; since thus has it fre- 
quently been known to last for years, or through life, like the 
other chronic disorders of this nature: yet not often without 
those interruptions or substitutions which occur in every habi- 
tual intermittent. If however the patients' reports could be 
trusted, I have known one case where it continued under quo- 
tidian type for sixteen years, and another where the tertian form 
of it lasted upwards of twenty; in both, as I was assured, with- 
out even a day's interruption. Nor is there any reason why 
this should not be true; as the same happens notoriously in sim- 
ple intermittent. And it is proper to remark here, that as it 
then becomes difficult of cure, or incurable, like other chronic 



252 PERIODICAL HEADACB". 

intermittens, and particularly, like these, does not yield to the 
usual tonics, this has been used as an argument against its iden^> 
tity with intermittent; it being forgotten that the simplest form 
of this disease is equally refractory to this treatment, when of 
long standing. 

To take the most regular form of a paroxysm, as the most 
proper mode of describing its attack, it will be found that this 
is as regular in its returns as that of a common intermittent, 
subject however of course to the analogous anticipations, post- 
ponements, or uncertainties; and, as in certain obstinate and 
long-continued disorders of this character, it will also be found,, 
that the same hour, almost indeed the same minute, is accurate- 
ly preserved, even through a long life, and though it should 
have undergone great and frequent interruptions; and that this 
singular regularity also marks the more slender derangements 
occasionally substituted for it, which I shall presently notice. 

It appears to me, that, as in the violent Neuralgia, and, as I 
believe indeed, in all the anomalous intermittents where pain is 
a symptom, the pain appertains to the hot fit of an intermittent 
paroxysm, and that in most cases, in all w T ell-marked ones, an 
attentive observer can trace the whole proceeding. The pre- 
vious cold stage is indicated by the same appearance which I 
have so recently described, in all respects; and if an absolute 
general hot-stage does not occur, there is that excitement of the 
vessels and local heat, often approaching, or even amounting to 
temporary inflammation, which marks at least a local hot fit; a 
hot stage as local as the previous cold one commonly is, just as 
if the whole intermittent paroxysm was limited to one spot, in- 
stead of occupying the whole nervous system. 

I need scarcely repeat that the pulse undergoes those changes 
already described; that thirst, and in short every peculiar symp- 
tom of an intermittent paroxysm may equally be observed, and 
with sufficient ease when the disorder is well marked. The 
characters are, in short, in every manner, those of an ordinary 
intermittent, with the addition of pain; proving the correctness 
with which it is arranged as a neuralgic intermittent. And un- 
der this view it is, that we so easily explain the other symp- 
toms which so often attend it; such as previous yawning, in- 
creased and sudden secretion of urine; spasmodic and hysterical 
affections, derangements of the mental faculties, and, as I con- 
jecture, vomiting. In this particular disorder, that act general- 
ly occupies the same place in the paroxysm which it does in the 
common intermittent; and though I do not doubt that there is a 
headach terminating in vomiting, of a different nature, and com- 
monly called the bilious headach, I have had no difficulty in 
tracing many of the reputed cases of this nature to the disorder 
which I am now describing, 



PERIODICAL HEADACH. 253 

Variety in the mode and extent of a pain, in the ordinary 
painful diseases, is a subject beneath scientific notice in physic; 
but it is here of considerable importance, and requires exami- 
nation. As always happens when striking symptoms engross 
the whole notice, it has here given rise to unfounded distinctions, 
or to a multiplication of imaginary independent diseases; but 
besides this, which is an error to be rectified, these varieties 
enable us to trace a connexion or identity among disorders that 
have been too often supposed different, and, very especially, to 
prove the identity of the simplest headach of this nature, with 
the most violent Neuralgia of the face. 

And if I may here venture for a moment to anticipate what 
belongs to the theory of this disease, it is not difficult to see how 
every variety of pain may here proceed from one cause. If it 
is an important nerve or a large branch that is disordered, the 
pain is proportional, as in severe Neuralgia; if that disorder be 
confined to the minutest ramifications, it is easy to understand 
how it may be milder and more diffused; while, in every case, 
it will also occupy an extent corresponding to that of the affected 
nerves, and appear under a severity which, probably, is propor- 
tioned to the degree of this obscure derangement. 

In the best defined periodical headach, the pained part is ge- 
nerally small, when it may exist in any spot, including the face; 
and it is a general rule, though not without its exceptions, that 
in the chronic cases, whatever spot is once the disordered one, 
it continues so throughout the whole career of the disease; in- 
dicating a permanent morbid condition of some nerve, as in the 
decided Neuralgia of the face. And thus, as these cases be- 
come severe in point of pain, do they approach so gradually to 
that Neuralgia, that no boundary whatever can be drawn be- 
tween them; a fact which ought long since to have explained 
what the Neuralgia (Tic) really was. 

Such very local forms of this disease sometimes occupy a 
point so small, that, as patients express it, they might cover it 
with the end of the finger; another character in which it agrees 
with the Tic: and thus it is not uncommon over the eyebrow or 
on the top of the head, though it would be trifling to point out 
these variations, interesting as they may appear to the patients 
themselves. How often clavus hystericus, as it is called, may 
be a different and an original disease, or a symptom in some 
other nervous affection, I am unable to say: but I have myself 
met with no case under this name which was not the disease in 
question, while the hysterical or nervous symptoms that some- 
times accompany that pain, are easily explained from the facts 
that have formerly been detailed. 

To pass over the less important varieties, I may next notice 



254 PERIODICAL HEADACEL 

that which occupies one side of thjs head: even thus, varying in 
its extent, from the most definite hemicrania, to pains occupy- 
ing more or less of the head itself, or reaching to the face, or 
even affecting the face exclusively: passing, in this last case, to 
what is called rheumatism of the face and toothach; disorders 
which I must, however unwillingly, separate from this, in con- 
formity to general opinion. In this, as in all cases of greater 
extent or wider diffusion of the pain, that is commonly more 
moderate than when it is confined to a smaller spot: and thus the 
headachs of this nature may vary from a state of great severity 
to one where positive pain can scarcely be said to be present, 
and where there is rather a sense of uneasiness, or fulness, or 
weight, or perhaps of throbbing, or of mere heat, generally 
however attended with that confusion of thought which is rare- 
ly absent during a paroxysm of this disease, and which some- 
times is even almost the only thing which a patient can fix on. 
It is not my business here to inquire from how many other 
causes hemicrania may arise, nor how often it may be a sepa- 
rate disease or a symptom of some other disorder: it issuificient 
that it is one of the modes under which the disease in question 
appears. 

I must now remark that this modification sometimes occurs 
under a form so slight that it attracts no notice; not at least from 
a physician, assuredly, and scarcely even from the patient; par- 
ticularly if accustomed to severer attacks, or engaged in active 
life. It would be a matter utterly unworthy of notice here, did 
it not tend to explain some of the circumstances, and some also 
of the errors, respecting this disease. Thus a paroxysm of it, 
and even of the most regular and persistent form, may occur as 
a mere sense of fulness or heat in one side of the face, often at- 
tended with a watering, or even a slight redness of the corres- 
ponding eye, and with a sense of fulness in the nostril, or even 
with a temporary catarrh of that nostril alone. Here, even the 
patient, uninformed as to this, will attribute these feelings, if 
indeed he should attend to them, to a cold, or to an inflamma- 
tion or "weakness" of the eye, and the true nature of the dis- 
order is overlooked; though, if it were watched, it would be 
found that these symptoms were as well marked in point of time 
and returns, as the most severe periodical headach or common 
intermittent, and that they were, in fact, regular paroxysms of 
the habitual disease. Of this species of hemicrania connected 
with a partial catarrh, I also find a notice in Sauvages, under 
the term Migraine: the hemicrania being periodical, recurring, 
as he says, once a year, and being attended by a dryness of one 
nostril, a retraction of one eye, and a considerable lacrymation: 
while no stronger proof can be given of his utter misapprehen- 



PERIODICAL HEADACH. 255 

sion respecting all these diseases, than lo find them scattered 
over every part of his work, and not seldom repeated under 
two or three different titles. 

It is an incidental remark here, but not without its value, to 
say, that I have seen cases of this nature where the lacrymation 
has been attributed to fistula, with consequences which I need 
not point out. Such deceptive fistula is therefore one of those 
occurrences which might add to the list of simulations in which 
Neuralgia, as well as intermittent, abounds: but if in the pre- 
sent division of what I consider Intermittent, I have not thought 
fit to make so marked and definite a classification of these false 
or deceptive disorders, I am the more unwilling to do so in 
such a case as this, where nothing but great neglect can commit 
the error; while further, respecting many others which I might 
easily have pointed out more distinctly, I have chosen to trust 
to the reader's own inductions, which ought assuredly now to 
be easy, rather than prolong this essay by minuteness, and in 
some measure also, by repetition. 

In speaking of a certain catarrh as being probably connected 
with intermittent, I alluded to that catarrhal affection of one 
nostril which I have just pointed out, as offering a kind of con- 
firmation of the possibility of such a disease. And on this I 
may now further say, that this periodical catarrh sometimes so 
predominates over the headach, as to appear the sole disease; not 
unfrequently also being of a severe and durable character, while 
then also, by what is called sympathy, often affecting the other 
nostril, and thus entirely deceiving both patient and practitioner 
into the belief that it is an ordinary catarrh. Such an affection 
often teases a patient through months, or even years, as do all 
these diseases: and if I have thus little doubt that many of the 
habitual catarrhs do belong to this hemicrania, this fact still fur- 
ther confirms what I formerly remarked respecting the catarrh 
of intermittent, while the order which I was obliged to adopt 
has forced me to notice this subject in two places. I need not 
add that this, like the preceding, is a case of simulation, which, 
but for the same reasons, might have justified an even more 
pointed notice. 

An important observation to be drawn from the former appa- 
rently trifling circumstances is, that where paroxysms or periods 
thus slender are irregularly interposed in any manner among 
decided ones, a disease which is perfectly regular in its returns 
may be supposed irregular, or may seem to have disappeared 
when it is actually existing, or has been continuous; and thus a 
truly periodical headach, or a most regular intermittent, is mis- 
taken for a common or an occasional one, because the ordinary 
attention is fixed only by the most obvious symptom. Hence, 
not only a perpetual source of errors as regards headachs in ge- 



256 PERIODICAL HEADACH. 

neral, but an hostility against this theory; because the practi- 
tioner does not see, or possibly has not had the means of seeing, 
what really exists; though the leading cause is the want of that 
true theory which would incite to a just observation, and cor- 
rect erroneous ones. 

That the fact as I have now stated it may gain the support 
which it really can command, it is easy to see that the relation 
here between such a trivial paroxysm and a decided and painful 
one, is exactly that which, in the simple chronic intermittent, 
occurs between those well-marked fits to which the disease is 
subject, and the very slender ones formerly noticed, which few 
but the patient himself, accustomed to their indications, w T ould 
observe; while in both cases, the regularity and the true cha- 
racter of the disease are equally maintained. And if this fact 
may aid in the proofs respecting the true nature of all these pe- 
riodical diseases, it is of much more value in relation to the 
cure; since in pointing out error and conducting to the real 
cause, it also indicates the proper remedies. Of such import- 
ance may observations apparently so trivial, and derangements 
of health so trifling, be rendered, by a proper induction; as, in 
all the sciences, there is no fact so minute or neglected, which 
he who knows how to wield that science, will not know how to 
turn to account. 

I shall offer but one remark more on this modification; and 
it is to point out that increase of action in the superficial vessels 
which so often attends it, and which in the nostril and the eye, 
as I just observed, reaches to temporary, and occasionally, in- 
deed, to more continued inflammation; while further, attacking 
the membrane of the mouth, it often seems to threaten tooth- 
ach, or to make the patient doubt whether he is not about to 
suffer this disorder. As it is a greater degree of that increase 
of action in the neighbouring vessels which attends all Neural- 
gias, so is it that tendency to the more decided inflammation of 
the eye and of the membrane of the teeth, commonly called 
rheumatism, which I shall hereafter attempt to arrange under 
the same head; forming the connecting link between temporary 
excitement and permanent inflammation. 

I must yet, however, notice one point of resemblance be- 
tween the common intermittent headach, and the Neuralgia 
(Tic) of the face. In the former, as in this, there are often two 
pains, an acute and a general one, at the same time; while the 
acute pain also is subject to similar intermissions and exacerba- 
tions during the paroxysm. And, when the disease is strongly- 
marked, or the pain intense, the confusion of thought formerly 
noticed frequently amounts to absolute delirium, as the whole 
disease is commonly attended with those affections of the mind 
or temper, which were formerly enumerated under simple in- 



PERIODICAL HEADACH. 257 

termittent fever. Thus further does this disorder, as well as 
the Neuralgia under whatever form, frequently excite the de- 
sire for suicide, while the very act itself has been committed; 
of which I shall hereafter be compelled to notice one peculiar 
case. 

If I have formerly pointed out the occasional effect of inter- 
mittent on the intellectual faculties, I must also notice the pa- 
rallel consequences which occur in the periodical headach; as is 
no less true of the Neuralgia of the face. In cases of long 
standing and of a continuous nature, and particularly, I pre- 
sume, if of great severity, this hebetude, or tendency to fatui- 
ty, appears at first only on the days of the paroxysm; but, at 
least, where bleeding has been erroneously used as a remedy, 
or any other debilitating system pursued, the faculties become 
permanently affected; though whether this is common in cases 
where the disease has not been thus maltreated I know not. In 
two very marked instances, and in persons of previously strong 
intellectual faculties kept in constant action, permanent debility 
of mind was the consequence through life; while in another, 
where no plan of this nature was followed, where in fact every 
remedy was refused, the disease, which was of a tertian and re- 
gular type, gradually lost its severity through a course of some 
years, when there as gradually supervened a species of fatuity 
which maintained as regular a tertian period as the painful state 
had done before, occurring only on the alternate days, and which 
continued for many years that this person was in my view; 
which indeed, I have some reason to think, has at length near- 
ly destroyed the patient's faculties. On the possibility of such 
an intermittent fatuity, I may quote an analogous case from the 
Mem. Acad. Sciences, Paris, in which a periodical loss of me- 
mory is thus described under the term Oubli cephalalgique ; 
being evidently a modified case of the same nature, or perhaps 
an absolutely similar one, though ill explained, because not right- 
ly understood; as usual. 

In treating of the chronic remittent and intermittent, I former- 
ly took occasion to notice that headach seemed sometimes to be 
the only very decided affection appearing to mark the continu- 
ance or the relapses of the disease. Yet, in such cases, there 
is, and perhaps very generally, a degree of general disorder, or 
of fever, greater than that which occurs in any of the cases of 
common periodical headach. I know not, nevertheless, whether 
it is here worth while to point out a general, and an apparently 
ordinary headach, as one of the varieties under which the disease 
under review appears, as it is creating distinctions without a real 
difference. Yet perhaps it cannot well be avoided; from the or- 
der, or rather want of order, which, in submission to popular 
opinions, I have been obliged to adopt. 

33 



258 PERIODICAL HEADACH. 

Be the propriety or the impropriety what they may, it is cer- 
tain that the periodical headach sometimes appears as a general- 
ly diffused pain, without any such peculiarity of character as 
might induce us to refer it to the Neuralgias; even here, howe- 
ver, under those several modifications as to the quality of the 
pain, which are far too familiar, in headach in general, to re- 
quire specification. If such a headach should have periodical 
returns, or be attended with any of the peculiarities already de- 
scribed, it may be marked as a disease of this nature; while, 
should it be very irregular, its true nature may even then be 
discovered, by a careful attention to all the circumstances of 
such irregularity, to the previous history of the patient, and to 
such other discriminating points as I need not again repeat. 

The judgment is, however, much more difficult in this case 
than in any of the former; as the most vulgarly discriminating 
characters, consisting in the mode of the pain, are wanting, and 
as the popular opinions respecting headach as an original disor- 
der, or as one originating from a variety of causes besides this, 
tend to mislead the observer and the patient both. It is not for 
me here to inquire respecting all the causes of headach, endless 
^is they seem to be: nor in truth has physic succeeded particu- 
larly well in explaining any one circumstance that belongs to 
this common disease, or symptom, be it which it may. But if 
we are still thus ignorant, there is no reason why we should not 
attempt to separate those cases which come under the variety 
under review; since, if we do not, even here, know the exact 
cause, w r e have at any rate approximated to it, and are in posses- 
sion of analogies at least which are important to the cure. 

And I have reason from observation, (not however so exten- 
sive as I could wish, since this disorder seldom comes under the 
cognizance of physicians,) to think, that if all the cases in which 
patients are subject to frequent headachs were carefully exa- 
mined, a considerable proportion of them would be found to 
originate in this cause, and that this would particularly prove 
the case in disorders of this nature popularly called nervous 
headach, generally the torment of a course of years, and some- 
times of life itself: a disorder that is often endured, if not with- 
out complaint, yet without application to medicine, from the 
opinion that it is incurable, and as the phrase is, constitutional. 
I must speak with great caution respecting a disease, of which 
it is so difficult to gain the management, and which can seldom 
therefore be properly studied; but it is one which well deserves 
to be narrowly investigated, under whatever form it may ap- 
pear, wherever it occurs and admits of such inquiry; since* 
should it at any time prove to belong to the variety in question, 
we are at least not absolutely without remedies, however often 



PERIODICAL HEADACH- '259 

fdey may disappoint us in every intermittent disorder that has 
been of long standing. 

On this point I must yet remark, that after consulting nume- 
rous, and even professed and distinct treatises on the headach, 
I often perceive the most utter neglect with respect, to .the in- 
termittent or neuralgic variety, even in its best marked forms, 
long as it has been known to physic and physicians. If bark 
is recommended, it is not from any definite view of its connex- 
ion with intermittent fever, but apparently from some empiri- 
cal association between the two terms intermittent, and bark, or 
perhaps arsenic; while the neglect of the other means applica- 
ble to intermittent fever, seem to prove that this criticism is 
justly founded. With respect again to headachs not rigidly pe- 
riodical and intermittent, I cannot any where trace even a sus° 
picion that they may belong to this disease, though I shall, be 
gladly corrected by any one of more extensive reading on this 
subject.- while I need not say that the greater number of these 
writers, and the recent ones in particular, are always seeking 
the cause in derangements of the digestive organs, (the fashion- 
able seat of most chronic disorders,) whether these are present 
or not; while the remarks formerly made on dyspepsia, show 
that they must often be present, yet as appendages, not causes 
of the disease in question. 

If I have thus examined with as much detail as appeared use- 
ful, the periodical or intermittent headach, there still remains to 
be noticed, an affection, or a collection out of some of the pre- 
ceding symptoms, for which I<ean find no better place. I know 
not well what to call it, from its half imaginary half mistaken 
nature; while I should assuredly not have bestowed a paragraph 
on it, had it not been for the pernicious practice to which it has 
led, and which, being one among the fashions of the day, seems 
also to be rapidly increasing. Though it is not a disease, nor 
even a symptom, nor any thing else that can.be defined, con- 
sisting as it does in a false and irregular view of many symp- 
toms, what is here meant will be understood, when I repeat the 
fashionable term by which it is known, namely, " a flow of 
blood to the head." 

I am not under the necessity of inquiring what is meant, 
physiologically, by the phrase, a flow of blood to the head, while 
I conjecture that those who use it so readily, would be some- 
what troubled to explain their own meaning; nor is it within 
my compulsory limits to discuss those cases, be they apoplexy, 
phrenitis. or what they may, in which a derangement of some 
kind, of the circulation within the brain, does take place. In 
the cases to which I allude, it has been recently discovered, (for 
the disorder is of very recent invention,) that the blood flows 
in some very improper manner to the head, even should the pa- 



2b0 Periodical headach.. 

tient be a delicate and young female, a pallid and enfeebled, 
night-watching student, a nervous lady of fashion, exhausted by 
London vigils, or any one else of all those who were once es- 
teemed to suffer from debility and nervous diseases; a tribe too 
numerous to mention in detail. Who was, or who were, the 
enlightened discoverers of this new philosophy, may be asked 
by those who can themselves answer it: a physician must hope., 
for the honour of his profession, that it was the discovery of 
the cuppers, and that it has been propagated by the self-empi- 
rics who are now fast becoming the rivals of his brethren, in 
the science, and of the apothecaries, in the art. 

It belongs to another subject, and not to mine, to investigate 
the various disorders, whether of the general system, or of the 
digestive one, which give rise to those numerous, yet often tri- 
fling affections of the head, to which this modern philosophy 
has been applied; affections formerly esteemed nervous, and, if 
not exactly explained by the term sympathetic, yet well under- 
stood under that received name. That which is here my bu- 
siness, is to say that this kind of derangement, or these symp« 
toms, unquestionably often sufficiently teasing to an irritable 
constitution, occasionally also in themselves not a little trouble- 
some, but always aggravated in the patient's mind by the spe- 
cies of terror or anxiety to which this false view of their na- 
ture gives rise, are very frequently the produce of the intermit- 
tent affections of the head which I have been describing, or are 
actually cases, if sometimes obscure ones, of the periodical head- 
ach; disorders of a neuralgic character. 

From what I have already said of the modifications of that 
disorder, it is easy to see how its characteristic and explanatory 
symptoms might be overlooked, and how the pain itself, under 
many of its forms, might be conceived, by those who have 
adopted such a false theory, to indicate even a serious local dis- 
ease of the brain. But there are other symptoms attendant on 
this disorder, which tend still more thus to mislead: while, in 
the minds of those who are ever ready to attribute every affec- 
tion of the head to " fulness of blood," " flow of blood to the 
head," and so forth, they have confirmed this false theory, as 
they continue to furnish arguments for its support. If I alrea- 
dy pointed out some of these, I thought it most advantageous 
to reserve others to this place; and I may now notice the whole 
together at the hazard of some little repetition. The real, or 
practical importance of this disorder, if disorder it can be called, 
though it is of an artificial importance and the produce of erro- 
neous practice, will justify my thus dwelling on what I should 
otherwise have passed over, and trusted to the reasonings of 
those who have read the account of this disease just given. 

Lest, however, it might be supposed that I am describing 



PERIODICAL HEADACH. 261 

symptoms to which I have myself given a wrong solution or a 
false colouring, I must premise that I have made use of no case 
for this purpose in which the real cause or nature had not been 
ascertained by all the tests which I have invariably applied to 
every one of these anomalous diseases; and chiefly by their pe- 
riodical nature, by their occurrence, as a variation, in persons 
subject to the chronic intermittent under several other anoma- 
lous forms, and by the fact of these affections alternating, even 
as single paroxysms, with paroxysms, either of common inter- 
mittent, or of intermittent headach, or of some other irregular 
form of this Protean disease. 

Where a prejudice respecting this "flow of blood to the 
head," as the necessary cause of all such disorders, is rooted, 
or among those who, entering on the practice of physic under 
such opinions received from teachers, are content to proceed, 
and to believe also, as others do, without inquiring, even com- 
mon headachs, when inveterate or habitual, are usually attri- 
buted to this cause, as are perhaps, even more commonly, those 
irregular ones which do not put on the highly defined character 
of a periodical or intermittent disease; while even this very dis- 
order in its most accurate form, is, now, not unfrequently attri- 
buted to this cause; such is the power of example, or the influ- 
ence of fashion. 

But if such pains are of the slight, transitory, or irregular 
character that I have described, they are also frequently neglect- 
ed, as trifling or unimportant, while the judgment is formed 
from the accompanying symptoms: and still oftener perhaps 
will such erroneous judgments be formed, when, as is not unu- 
sual, the pains are altogether wanting, or, as also happens, when 
they occur but occasionally amid the other more constant symp- 
toms. 

Of these, I have already noticed a sense of fulness in the 
head, which, in the hemicrania, is particularly remarkable, 
from the contrast between the healthy and the ailing division, 
and which, as I then noticed, may exist without any pain. Now, 
similarly, where a headach in this disease might have occupied 
the whole head, as a paroxysm, it may be replaced by this mere 
sense of fulness;. and thus is established the opinion of an ex- 
cessive and dangerous " flow of blood to the head." Such also 
is this feeling at times, as to convey the sensation of high ten- 
sion; while, further, this proceeds so far, occasionally, as to be- 
come a sensible throbbing; or the patient can feel the pulses of 
the heart in every part of his head without even touching it. 

It must be admitted that such symptoms carry with them 
every evidence of an increased action in the vessels of the head, 
or of a flow of blood to the head; and it is still less surprising 



262 PERIODICAL HEADACK. 

•to find prejudiced or inattentive practitioners misled by it, when 
the action of the carotid arteries is sensibly increased, and when, 
sometimes, the exterior jugular veins enlarge; both of them 
symptoms which occur now and then, in violent or particular 
cases. . And there is, in fact, a really increased action, so that, 
in words, the theory is more or less correct: while the impor- 
tant question still remains, what the nature of that action is, 
where it lies, and what is its cause: since, on the determination 
of this, must the practice, for good or evil depend. I hope to 
produce here, analogies enough to show what the practice at 
least ought to be, if I cannot explain in what this singular ac- 
tion of the blood-vessels consists. 

In the general description of common intermittent, I reserved 
chiefly to this place, the mention of a peculiar symptom which 
often attends it, and which, I must also remark, belongs to the 
hot stage. The fulness of pulse which succeeds to its peculiar 
condition in the cold stage, is well known, but it is attended, 
often, with a circumstance which scarcely occurs to the same 
extent in any disease that I know. This, difficult enough to 
describe in words, is a sort of bounding of the artery, as if it 
was displaced by some action of its own, independent of that 
of the heart, at each pulsation; and, when sought for, it will 
be found to extend through every artery of the body, so as to 
render sensible to the touch, numerous minute branches or deep- 
seated vessels which are never otherwise perceptible. And 
very often, further, it is so energetic, that the patient himself 
can, when lying at rest, feel and count the pulsations of such 
arteries, though nothing should touch them, and this, even in 
the fingers, to their very extremities, as in numerous other places 
which I need not suggest to anatomists. That this action also 
does really belong to the arteries themselves, is plain; because it 
is not necessarily attended with any such increased action of the 
heart, though this sometimes also happens, as might be ex- 
pected. 

Now this state of the circulation is but a part of the stage 
that I have mentioned, and is transitory; subsiding when that 
is past, and often so suddenly and completely, that we can 
scarcely believe what we have just witnessed,. when the change 
happens under our hands. Yet it is very often so far mistaken, 
as to be made the reason for blood-letting and the justification; 
after which, it of course subsides, affording still further proof 
to the ignorant or prejudiced, that this was necessary,, though it 
would equally have ceased at its natural period, had nothing 
been done. Should this practice be repeated on every new oc- 
casion of this nature, in a quotidian, or even in a tertian, it is 
very certain that the patient would not long trouble his surgeon; 



PERIODICAL HEADACH, ^63 

while, in fact, it is a mistake perpetually committed, and with 
consequences which I shall have occasion to point out here- 
after. 

I have here described an acute intermittent,' but the truth is, 
that the very same symptom often occurs in the chronic dis- 
ease; and it is far from uncommon to find cases of this nature, 
in which the only very ostensible symptom of this paroxysm 
is this temporary and singular state of the arteries, though it is, 
in reality, always preceded by one of those obscure cold stages, 
which I have already noticed. And in some of these cases, also, 
the heart seems more affected than the arteries, or the patient 
counts the return of his paroxysm by an increased action of 
that organ, not amounting to palpitation, but obviously connect- 
ed with it, or being a milder form of that local symptom. 
If this, and the palpitation also, is a partially increased action 
in the arterial system, so may that action of the inferior aorta 
which I formerly mentioned, be viewed in the same manner; 
and if, when the intermittent is universal, or the whole nervous 
system affected, the entire arterial system is thus acted on, it 
is not difficult to admit that a portion of it may be similarly de- 
ranged when the intermittent acts, rather partially than univer- 
sally, on the nerves, as it in reality does in the cases of the 
heart and of the aorta: when it is of that character which gives 
us all the local affections, be they Neuralgias or what not, which 
have already been described. 

Now it is easy to transfer this reasoning to the diseases of 
the head, under consideration, since the analogy is striking. 
Here, the local disease prevails over the general one; or the in- 
termittent, instead of occupying the whole system, is limited, 
or chiefly limited to the head. It is acting on the nerves of 
the head and face when it produces Neuralgia, a common peri- 
odical headach, or the more general "nervous" or "rheuma- 
tic" headaeh: and thus would it be easy to foresee that it should 
act, or might act, especially on the arteries of the same parts, 
supplied by these diseased or suffering nerves. It would be a 
local hot fit with augmented arterial action, just as there is a ge- 
neral hot fit with this symptom; and I have already shown that 
the painful state of periodical headach or Neuralgia is the hot 
fit, and that this stage is often, like the cold one, absolutely lo- 
cal and limited. 

And if such might be the presumption a priori, it is con- 
firmed by other facts. I have elsewhere mentioned partial in- 
termittents affecting a single limb, or more, or less; and, of 
these, some remarkable cases are mentioned by authors, w^here 
the paroxysm has been so complete and so regular, that each of 
the three stages took place in the part, while the body at large 
was unaffected. In such cases, it is plain, the arteries c( that 



264 PERIODICAL HEADACH. 

part must, during the hot stage, have been in the very condition 
here described; while it is obvious, that not only the same might 
take place in the head alone, but that this must be a frequent 
event, when it is thus proved that hemicrania, or periodical 
headach under any of its forms is such a partial intermittent: 
the probability of that disorder being really an intermittent, 
being further confirmed by the occurrence of these other partial 
cases. 

Moreover, in Neuralgias, every where, and in these headachs, 
there is an increase of the action of the smaller arteries, as I 
have formerly shown; producing redness, or temporary and tran- 
sitory inflammation, or else causing actual inflammation, as it 
does in the i( rheumatism of the face:" and further, as I shall 
show hereafter, giving rise to a peculiar ophthalmia, a neuralgic 
ophthalmia. Indeed, even in a common headach, where the 
smaller nerves of the membrane are the seat of the pain, there 
is increased action, or excitement in the neighbouring arteries, 
as is well known; extending often even to the larger ones, and 
even while the heart is unaffected and all the rest of the vascu- 
lar system tranquil. So certain is it that undue arterial energy 
can be excited by locally disordered nerves, in a single spot, 
without fulness of blood, or " flow of blood to the head/' or ten- 
dency to inflammation or to plethora, and even in subjects la- 
bouring under the most opposite conditions of exhaustion and 
debility. With this indeed, under various modes, physic is 
far too familiar to render it necessary for me to point out the 
circumstances under which it happens. Even in these cases, 
modern fashion is now resorting to this pernicious theory, per- 
nicious in the practice to which it gives rise: when surely no 
physician really acquainted with disease, would consider that 
such partial increase of action in the vessels of the head, was a 
justification for blood-letting on the ground of a dangerous ple- 
thora or misdirection of the circulation. 

What the exact nature of this increased local energy of the 
arteries is, any more than what it is when extending over the 
whole system in the common intermittent, we do not know; so 
little do we really know of any thing in physiology or patholo- 
gy. One fact here I may however add; and that is, that in these 
local cases, it seems often to begin in the extreme vessels, and 
is from them communicated to the larger ones. But whatever 
it be, and whether in these particular cases it extends to the 
brain as it attacks the exterior small arteries, and even, as I re- 
marked, the carotids, there is no evidence of its exciting in- 
flammatory symptoms there; though we can conceive this pos- 
sible, at least under a certain form, since it produces this effect 
on the eye and the membranes of the mouth. If it were even 
thus, it is not a justification for blood-letting, but the reverse, as 



PERIODICAL HEADACK. 265 

it will shortly be proved that all the neuralgic inflammations are 
aggravated by this treatment, as is the painful part of the dis- 
ease itself under all its modes, and as is every chronic intermit- 
tent, be its form what it may; while further, real diseases of the 
brain, or injuries to the nervous power, are here produced by 
blood-letting, as I hare often noticed already, and shall have 
occasion to remark again. 

But further, if this increase of action of the vessels of the 
head is suffered to take its own course, it subsides within a li- 
mited time, or with the local hot stage which produced it: main- 
taining, and proving still more effectually and completely, the 
analogy which it bears to the parallel symptom in the common 
intermittent fever. This would not happen in any other case of 
diseased, inflammatory action, either in the brain or in any 
other part: and it ought itself to be a proof that blood-letting is 
here unnecessary, (while it is in fact injurious) and that the 
common theory of increased action or flow of blood, true as it 
is in words, is false as it relates to science, in the view common- 
ly taken of it, and pernicious as it relates to the treatment. 
And as far as it relates to the possible termination of this in- 
crease of action in membranous or u rheumatic" inflammation, 
which is the only kind of inflammation that does follow it, I 
may observe that this event is very rare, compared to the cases 
where it does not occur, and therefore diminishes the force of 
even the false arguments in favour of this practice that might be 
derived from it: while even that inflammation, where we can 
really prove its existence, is of a peculiar character, so as, al- 
most universally, to be aggravated by evacuating and debilitating 
remedies, as I shall have occasion to prove fully hereafter. 
Such is the view that I have taken of this particular symptom 
or collection of symptoms, now called the " flow of blood to 
the head:" and if I have noticed it, as was here my duty, as 
belonging to the periodical headach or local neuralgic intermit- 
tent, it seems to me that nearly the same reasoning, with the 
same practice, applies to all the cases where these symptoms 
occur, whatever may be their original causes; since, in all, the 
pathological condition is similar. 

The only other symptom or disease which I think it worth 
while to notice, is giddiness, vertigo in medical language; not 
only because of its occurring as a prominent symptom or local 
intermittent, but from its leading, even more decidedly than the 
last named, to the same erroneous and pernicious practice. This 
I may consider as one of those marked simulations which might 
have demanded for itself a separate division, or which I might 
have arranged in a distinct class with others which I have si- 
milarly but touched on where it seemed convenient; since, in 
strictness, it does not appertain to the present place. But if, 

34 



266 PERIODICAL HEADACH. 

for want of a better one, I have been obliged to speak of it here^ 
I must observe that it does not necessarily belong to the period- 
ical headach, though often occurring with these; since I have 
seen it occasionally as a mere variation of the common chronic 
intermittent; a substitute for ordinary paroxysms or for other 
anomalous ones, and without pain. 

I formerly spoke of the intermittent lethargy or coma, a con> 
mon source also of erroneous judgment and mischievous prac- 
tice; but the giddiness in question is unattended with lethargic 
symptoms, and as far as I have seen, does not even affect the 
mental faculties. In every thing but this, it resembles the gid- 
diness of intoxication, so that the patient, with all his efforts, 
cannot walk straight, or, when it is excessive, fancies the neigh- 
bouring objects are in motion. It is a symptom well known as 
occurring from certain poisons, and also in nervous affections; 
in some of which at least, where recorded, it is not unlikely to 
have depended on the cause under review. 

When it attends the intermittent headaeh, it either actually 
accompanies the pain, which is occasionally a mere neuralgic 
point, or it comes alone alternately with that, or else it will re- 
turn periodically, for even weeks, by itself; and in this last mode 
also I have known it replace an ordinary chronic intermittent. 
If its accuracy of period or duration is subject to the various ir- 
regularities which I have formerly pointed out in all these chro- 
nic and anomalous intermittents, they can now be easily ex- 
plained by the reader; while I need not further detail the cha- 
racteristics by which it is to be distinguished, since it would be 
to repeat much of what has so recently preceded. But all these 
facts must be kept in mind; since the prejudices with regard to 
the value of this symptom, being the same which have just 
come under review, tend similarly, or perhaps even more, to 
mislead the practitioner, and indeed the patient also. It requires 
in fact, no small degree of moral courage in a physician, to re- 
sist, or change, the mischievous practice resorted to in these 
cases; and very particularly, should the patient's age, quality, 
make, or habits, confirm himself and his friends in the opinion 
of a threatened apoplexy. 

If I need not dwell further on this symptom, since it would 
be nearly to repeat what I have just said, neither need I add 
much respecting the practice, since that also would be to repeat 
the preceding remarks and cautions. The paroxysms disappear 
of themselves, as do all others; and thus also will the entire 
course of such a symptom, as so often happens in all these chro- 
nic intermittents: and if remedies are to be resorted to, they are 
those which are applicable to the whole tribe, and which will 
be examined, as far as they have not yet been so, hereafter. 
The injurious practice is the same; while, besides blood-letting 



PERIODICAL HEADACH. 267 

and cupping, low diet is also a favourite remedy in this case. 
Of this, the evil may be conjectured from the former remarks 
on that subject; and the result of the whole is to produce a vast 
train of other evils, to which I have already alluded, and even, 
as I have more than once seen, death. Whether this result, un- 
der such treatment, has any peculiar connexion with these local 
diseases of the head rather than with other forms of intermittent, 
I cannot conjecture; but I have seen one such case, vertigo, 
where successive blood-letting and cupping produced, and so 
gradually that the cause could not be mistaken, a confirmed and 
very frequent epilepsy, which was nevertheless cured after some 
years, by a change of practice, together with all the other inter- 
mittent diseases which had, from the beginning, been sufficient 
to prove the true nature of this vertigo. 

I may now terminate this account of the intermittent or pe- 
riodical headach, (the neuralgic intermittent of the head,) and 
of the disorders or derangements which it was convenient to 
connect with it; but there remains yet one case which I must 
place here, because I know of no other so convenient. If but 
one has occurred in my own experience, and that I am weary 
of unsuccessfully searching through authors for information, it 
is not impossible that some of my readers may be able to add 
to it from their own experience. This was a case of periodical 
and quotidian deafness, so regular in its attacks that no doubt 
could be entertained of its real nature; particularly as that was 
confirmed by the former diseases of the patient and by other 
alternating symptoms. That such deafness does sometimes oc- 
cur in the cold fit of an acute intermittent, I have formerly re- 
marked: and since I have also shown that many of these pecu- 
liar local affections or anomalies occur equally in the chronic va- 
rieties, if under differences already explained, it is easy at least 
to admit the possibility of such a periodical deafness from chro- 
nic intermittent; while it is plain that I might have ranked this 
case in a former chapter instead of the present one. It has not 
always been easy to determine on the best place, amid the divi- 
sion which I was compelled to adopt for the Neuralgia. 



[ 26$ ] 



CHAPTER XII. 

Of the Neuralgias of other Nerves in various parts of the 

Body, 

The description which I have given of the Neuralgia (Tic) 
of the face has been purposely made minute, that I might not 
again be obliged to enter into such details in describing this dis- 
ease as it occurs in other parts of the body. And if in treating 
of the periodical headach, I have entered into similar details, 
and into reasonings somewhat extended, it was partly also that 
I might not again be obliged to go over the same ground in what 
is to follow. Between the two, I have shown that the neural- 
gic diseases are periodical, and connected with common inter- 
mittent, reserving however some further proofs and arguments 
to a later period of this essay ; and in the account of the one or 
the other, almost every essential circumstance that can occur in 
the other Neuralgias has also been explained. Thus, where a 
large branch is affected in any other part of the body, the case 
and the symptoms are referrible to the Neuralgia (Tic) of the 
face; while the affections of the minute ramifications produce 
symptoms or disorders analogous to those noticed under peri- 
odical headach, but difering in situation. It might be inferred 
also that the quality of the pain, or the symptoms in general, 
would be partly regulated by the peculiar nature or offices of the 
affected nerves: and accordingly such variations will be found 
to occur. 

As long as the unfortunate term Tic douloureux continued 
solely allotted to this disorder, it was scarcely conceived that it 
could exist any where but in the face; and it is but recently that 
the existence of other Neuralgias has been admitted, while, even 
now, this belief is very limited, and indeed the fact itself de- 
nied or doubted by many. And if we refer to authors, we shall 
find many cases recorded of painful diseases, (though it is com- 
monly the most remarkable ones that have been selected,) where 
it is evident that the disorder could have been nothing else: 
while we also find them sometimes represented as wonderful or 
mysterious, and not unfrequently are almost inclined to smile at 
the suppositions produced, or at the ambages of the narrators 
in attempting their explanation. 

Within the circle of our own observation, if we meet with 
the same circumstances, we can more easily perceive the mis- 



VARIOUS NEURALGIA. 269 

takes, both in practice and opinions, respecting these cases: mis- 
takes so common, I may almost add so universal, that there is 
no physician who, if he shall adopt this view and reflect on his 
own experience, will not be able to recollect endless cases of 
this nature, and I might almost say, scarcely one in which the 
true nature of the disorder has been understood. It will natu- 
rally be asked, as was formerly remarked of Tic itself, for what 
they have been, for what they are now mistaken; but the answer 
would be as long as the places where they may occur are nu- 
merous. Rheumatism and gout have perhaps sufficed for the 
most frequent solutions: the latter having been often called on 
to countenance or father many more diseases than this. I have 
already mentioned an instance where the pain was attributed to 
a diseased bone, and many more such have come under rny no- 
tice: while scirrhus, strictures, diseased glands, and far more 
than it is worth while to name, have equally been the excuses 
for ignorance, where the peculiarity of the situation admitted of 
such explanations. That also, among these Neuralgias, there 
are at least two which have gained specific names for them- 
selves as if they were independent diseases, I shall hereafter 
show. 

It might have been conjectured long ago, and with no very 
great effort of ability in the art of generalization, that if a nerve 
in the face might be thus diseased, so might any other nerve; 
and it does appear somewhat wonderful that Sciatica had not 
long ago led physicians to this obvious inference, at least for 
that particular case, had it done no more. And accordingly, if 
every individual nerve in the body has not been the seat of 
Neuralgia, it has occurred in so many, even in my own limited 
experience, that we have no reason to exclude it from any, but 
have, on the contrary, reason to expect, that whenever the dis- 
ease shall become generally acknowledged and observed, there 
will be produced cases of its occurrence in every part of the 
body, and that such disorders will also be found not less widely 
and commonly diffused. 

With respect to the evidence that the diseases which I am 
about to point out are truly Neuralgias, I may anticipate the fur- 
ther proofs that will hereafter be given, in a general summary, 
as also such particular ones as any of the remarkable cases here 
quoted may require, by saying generally, that they are of the 
same nature as those which have already been treated of on so 
many occasions. The quality of the pain is the same as in the 
one or the other of the analogous disorders occurring in the head; 
while there is neither organic disease, nor inflammation, nor 
gout, nor any of the other well known causes of pain present 
to justify it. It is periodical, or transitory, and recurrent, and 
through long periods of time, even through life: subject of 



270 VARIOUS NEURALGIA 

course to those irregularities in this respect which belong to all 
the chronic intermittents; the nature and causes of which have 
already been explained. Very often we can trace it to the same 
causes; and while it is cured by the same general remedies as 
common intermittent, with the addition of such local ones as are 
found of use in the Neuralgia of the face, it is exasperated or 
rendered permanent by that which is equally maltreatment in 
all those diseases: while also the very pointed evil consequences, 
produced by the evacuant and debilitating practice, are the very 
same or exactly analogous to what they are in Intermittent and 
in acknowledged Neuralgia, whatever be the place of the pain. 
Further, these pains, or painful disorders, be the situations what 
they may, alternate with common Intermittent, in the several 
ways already described as occurring in the local anomalies of 
that disorder, and in Neuralgia and periodical headach; that is, 
as whole periods, or as mere paroxysms: while, of course, they 
are also irregularly intermixed with such affections, as happens 
with respect to the whole of the disorders treated of in this es- 
say, whenever they are of long duration, or have become an in- 
veterate habit. 

Thus also, in a patient of this nature, it is not uncommon to 
find a very great number of all the disorders that have been here 
enumerated, co-existing or succeeding, and in every possible 
mode of combination and succession. The same patient, for ex- 
ample, who has suffered common intermittent, will be found to 
have also experienced more or less, or even the whole of the 
anomalies enumerated under that disease, together with the Neu- 
ralgia of the face, the periodical headach, and a certain number 
of the neuralgic diseases which I am about to record; all these 
several affections alternating in different ways among each other, 
and many being occasionally united; while, what renders the 
proof of the nature of these last complete, is, that whatever pe- 
riod is the habitual one of the commonest intermittent parox- 
ysm, the same will mark the recurrence of every one of the af- 
fections in question. Such a patient, (and I have seen more than 
one such,) becomes in himself a perfect nosology of this dis- 
ease, and carries in his own person a demonstration that ought 
to convince the most incredulous. Lastly, I have never seen 
a case of these remote and less common Neuralgias, where it 
was not easy to trace that febrile state, which, however slender 
it may often be in all the local affections, is never absolutely 
wanting, and ought never to escape the eye of a real physician. 
The pulse undergoes the same changes, the fit of pain is the 
hot stage, and the cold stage may be found, at least by means of 
those delicate tests which I. have already pointed out: nor have 
I ever been introduced to a patient reported as labouring under 
pome unknown and extraordinary painful disorder, that I could 



various neuralgi.se. 271 

not pronounce at once, from the mere physiognomy, (taking 
care to be present before, or at the accession,) what the disease 
was, provided of course that it was really a Neuralgia, as, in 
truth, has almost invariably proved the fact. 

I have only now to add, with respect to the following Neu- 
ralgia, that as some of the cases were solitary ones, (a circum- 
stance which I must attribute, I presume, to my limited expe- 
rience,) and others were of a peculiar character, I have found it 
expedient to depart occasionally from the rules I had laid down, 
for the more common diseases of this character, and thus to give 
some cases in a degree of detail that I have elsewhere avoided. 
I believe, however, that this will have its advantages; as such 
minuteness and example will serve as a guide to those who 
have hitherto not attended to these diseases, better than a more 
general statement would have done. And if I must thus often 
repeat symptoms and circumstances that have already been dis- 
cussed, it was a proceeding which, on this plan, could not have 
been avoided. 

OPTIC NERVE. 

I can only presume that this was the real place of the disor- 
der, from the position of the pain, which was described by the 
patient as if a red hot needle had been passed deeply through 
the centre of the eye. As this disorder accompanied an attack 
of Neuralgia in the upper jaw, or rather replaced it, appearing 
at the moment when that ceased, and as it was cured by arsenic^ 
there was no reason to doubt of its nature. 

TESTICLE. 

Of this I have known, personally, but two cases, while I 
have reason to suspect that it has occurred frequently, and been 
mistaken for an incipient scirrhus. In one of the cases to which 
I allude, this error was in fact committed, and after a long pe- 
riod of suffering, the gland was extirpated in the usual manner. 
It was found to be sound, and, as generally happens when the 
division of the nerve has been resorted to in the Neuralgia, it 
returned in the cord. This case was known to me, only after 
this last event; and as the patient was an opulent one, there had 
been no want of advice respecting the disease. It must be 
hoped that such mistakes will now become less frequent; while 
I must not even allude to the place where this one was com- 
mitted. 

The other case, under my own care, was immediately cured 
by arsenic; while its nature was rendered perfectly evident by 
the slight paroxysm of intermittent which attended it, and by 
its having alternated with another Neuralgia. As might be sup- 
posed, the pain in this case was extremely violent; and it wafi 






212 VARIOUS ^EUxtALGI^l 

described by the patient as rendering him entirely blind (as he 
expressed it,) to the surrounding objects, as if the whole world 
had disappeared from his sight, and all recollection was oblite- 
rated. Had such a pain continued even for a few minutes, it 
must have produced delirium. 

Not to make a separate division of one, as yet solitary case, 
and of a case also perhaps not sufficiently marked to satisfy every 
one, I shall here barely notice that I have met with what I my- 
self believed to be an example of this disorder in the Palus: the 
mode of the pain and the attack, being precisely that of a Neu- 
ralgia, and the patient, a young and otherwise healthy man, as- 
suredly free, during the whole long period of this affection, 
(which was in the middle of the glands, not at the extremity,) 
from any affection of either kidneys, bladder, ureters, or ure- 
thra. 

HAND AND FINGERS. 

I have found many cases of this nature, but shall describe 
only two, on account of the particular circumstance attending 
those. In one, a patient who had suffered from chronic inter- 
mittent and Neuralgia in various forms, the affection was in 
that small branch of the radial nerve, which runs along the me- 
tacarpal bone of the fore finger. The usual symptoms were 
present, but the peculiarly superficial nature of this nerve, and 
its place on the bone, enabled me to determine a change of 
structure in it which can seldom be observed, and which is pro- 
bably always present, though it has been little suspected. Had 
it been extirpated, as was wished by a surgeon of high repute, 
I might have been enabled to ascertain more exactly what the 
nature of this change was; though it is a piece of pathology on 
which dissection has not yet thrown any real light, as I shall 
hereafter show: but I cannot concede that this species of mora- 
lity is justifiable, not uncommon as it may be. 

The pain was limited to a space which a pea would have co- 
vered, and in the progress of the disease, which lasted about 
four months, as no remedies were used, it gradually enlarged so 
as to form a knot, or swelling of similar dimensions; or, more 
accurately speaking, about a sixth of an inch in diameter. From 
the extreme sensibility of this swelling, which could not bear, 
literally, the touch of a feather without pain, there was no rea- 
son to doubt that the nerve itself was the seat of it; while I 
must further remark, that, even after the Neuralgia had disap- 
peared, the swelling continued, though gradually diminishing, 
for many years; nor has the nerve, even now after eight years, 
ceased to be irritated by a touch, for a considerable space above 
this part; the most gentle pressure producing, throughout it 
from the finger's end to a point high up in the arm, the well 



VARIOUS NEURALGIiE. , 273 

known tingling sensation which always follows the injury of a 
nerve. 

In this case also,, it was particularly easy to remark the high 
increase of sensibility, not only in the nerve itself, but in the 
surrounding skin, which attended the periodical paroxysm; and 
further, as indeed happens in many other cases, to trace the gra- 
dual progress of a painful state, upwards through the great 
trunk of the nerve, as the disease gradually increased in severi- 
ty. And further, I had here also an opportunity, very particu- 
larly, of watching the effects of blistering; which were invaria- 
bly to increase the painful state, and very remarkably to enlarge 
the circle of that general pain and irritation which so common- 
ly attends Neuralgia: and as the same experiment was repeated- 
ly tried with the patient's consent, the demonstration was high- 
ly satisfactory; confirming what I have ever found to be the 
fact in this disease, and, if I mistake not much, confirmed also 
by what happens in sciatica, where I at least have always found 
the effect of blisters mischievous. 

If the extreme sensibility of the parts here is at variance with 
what is familiar respecting pressure in this disease, I believe it 
all admits of explanation, with a very slight degree of atten- 
tion. Where a large branch is affected, rude contact or pres- 
sure, or should the nerve be superficial, as it was in this case, 
the slightest touch not only increases the pain, but very often 
excites a similar pain in some distant ne'rve, or causes a pain, or 
a tingling, or shooting, in the remainder of the diseased branch. 
But when the disease is seated entirely in the minutest cutane- 
ous or membranous ramifications, the pain is often diminished 
by firm pressure; while it is irritated, as I formerly observed, 
by a gentle superficial touch, even by drawing a feather along 
the surface. And further, in these cases, if the leading branches 
are sound, the pain is diminished by pressure applied to them; 
cutting off in some measure, we may suppose, the nervous com- 
munication. In toothach and headach, this effect is familiar, 
and well known to practised sufferers; who learn to find out by 
trial, where the chief branches of the nerves lie. And if it is 
true that exercise or motion of the parts always increases the 
painful state of Neuralgia, as is familiar in sciatica, it is easity 
explained from the disturbance of the disordered nerve pro- 
duced by the pressure of the muscles, or otherwise. 

Having noticed here this peculiar sensibility of the cutaneous 
ramifications, I may suggest the possibility, (for it is no more) 
that some of the singular cases recorded, of a morbid and pain- 
ful increase of sensibility in the skin, may have been of an ana- 
logous nature; Neuralgias of those nerves. Never having had 
the fortune to see such a case, I can but offer this as a conjec- 
ture, and as a suggestion to be verified or not, by future obser- 

35 



274 VARIOUS NEURALGIA. 

vation. No other cause at least has been proposed, and this one 
is possible; while that possibility is supported by the well- 
known augmented sensibility, not only in the skin, but in the 
hearing and in the sense of smell, which so often occur in in- 
termittent, as well as by the facts under review. 

It would be useless to detail in the same manner, all the dif- 
ferent cases of Neuralgias occurring in the fingers, which I 
have seen: I may confine myself to little more than the bare 
mention of two or three others, in which there were peculiari- 
ties, the indicating of which may prove useful to such of my 
readers as may not have had much experience in this disorder. 
The first of these was viewed as a cramp of an inexplicable na- 
ture, and had consequently been a cause of long continued suf- 
fering, under a trifling practice with antispasmodics. In this, 
there was a daily contraction, for a few hours, of the middle fin- 
ger, attended with considerable pain; and there was as little 
difficulty in ascertaining its real nature, by the physiognomy of 
the patient, as there proved to be in curing it by a few doses of 
arsenic. 

Another case had been mistaken for gout, the pain being 
seated in the knuckle joint of the little finger; while what ren- 
ders this instance remarkable, there seemed no intermission, or 
thus at least the patient positively asserted, during a month 
through which it lasted. It was complained of as very severe, 
and as occupying the space of a pea, while attended with the 
usual sensibility of the surrounding skin, but without swelling 
or redness at any time. This ought, negatively, at least, to 
have indicated its real character, nor shall I be surprised to hear 
of many more such cases when this subject shall be better un- 
derstood. In this instance also, I had an opportunit)*- of re- 
marking the evil consequences of blistering; nor could I in- 
deed have avoided that, since the mistake, like the practice, 
was my own; this somewhat obscure case having occurred in 
the earlier days of my investigations on this subject, and long 
before I was aware of its extent, or of the various appearances 
of Neuralgia. That I did not cure it by my practice, I am 
bound to add: but having instantly, in a minute in fact, disap- 
peared on the occurrence of a periodical toothach attended by 
an intermittent, which I doubt not I had previously overlooked, 
its real nature became evident; while numerous similar termi- 
nations since that time, have left no doubt in my mind respect- 
ing its real nature. The only other case of the occurrence of 
Neuralgia in a finger which I think it necessary to point out, 
was in reality a case in point: since, in this, the pain was sud- 
denly transferred from the finger to the face, producing a regu- 
lar Tic douloureux, which again ceased, to reappear in its ori- 
ginal place. 



VARIOUS NEURALGIA. 275 

KNEE. 

I think it particularly important to notice the Neuralgia of 
this joint, because in three of the cases which I have seen of 
this variety, it was reputed to be of a scrofulous nature, and to 
threaten what is called a white swelling. In one of the cases, 
it had lasted five years; and as the pain was very severe, the 
surprise had long been that no swelling could be discovered by 
the touch. Had these remote Neuralgias been then suspected. 
to exist, or had the disorder at large been understood, as I trust 
it will now be, it could not have remained a subject of doubt 
for as many days, since the attack was quotidian and accurate; 
and it is one, yet but one out of thousands of cases, which shows 
how necessary it is that the knowledge of this disease should be 
universally spread among practitioners, since the quantity of 
human suffering that has already resulted from that ignorance is 
incalculable. I need scarcely say that, in this case, gout and 
rheumatism had been resorted to for the solution, when, after 
some duration, no swelling or disease of the bones could be dis- 
covered. 

But one further remark on it is worth making. The pain 
had always been severe; and from that, and its long duration, 
the constitution of the patient, a female in the better ranks of 
life, was reported by the attendant practitioner, to be " broken 
down " by the suffering. A mere glance, however, was suffi- 
cient to show, not only that chronic intermittent was present, 
but that she w T as labouring under visceral disease, probably in 
the spleen; and thus it frequently happens in these cases, where- 
ever they occur, that such a state is ignorantly attributed to a 
ei broken-down constitution. " It is scarcely worth while per- 
haps to add, that the pain soon yielded to bark and arsenic, given 
alternately; but many more months, added to change. of air 
from the unhealthy and marshy situation where this patient re- 
sided, were required to quell the simpler intermittent which at- 
tended it. 

Of two other cases in this part, it is worth while to remark, 
that the extremely acute pain was situated over the very edge 
of the head of the tibia, yet between the harder parts and the 
skin, as the patient determined it; while the affected place was 
not more than the eighth of an inch in dimensions. As scarce- 
ly any accuracy of dissection could produce a visible nerve in 
this precise spot, it follows that a perfect and intense neuralgic 
pain may exist in the most minute branches; a fact which has 
occurred, in my experience, in other parts: so that the want of 
a demonstrable nerve must not be used as an argument against 
the existence of the disease generally, any more than it must be 



216 VARIOUS NEURALGIA 

permitted to blind the practitioner as to its possible presence in 
any individual case of difficulty. 

The last of these cases which I think it worth while to no- 
tice, was remarkable for its double tertian, or alternating, form; 
a fact not very unfrequent under different modes, and which I 
have noticed elsewhere. I think, at least, that the term double 
tertian may be applied to it, from its resemblance to that mode 
of the simple intermittent in which the two fits are dissimilar, 
and from its analogy to those cases, not uncommon, in which a 
lit of Neuralgia and a paroxysm of common intermittent occur 
on alternate days. And it>belongs to that class of cases in this 
disorder, which aids in establishing the common generic nature 
of all these diseases; being one of the links which connects the 
most simple and regular intermittent atone extremity, with the 
most obscure Neuralgia at the other. 

In this case, there was, on one day, a pain in both the knees, 
and, on the alternating one, a pain in one arm; and thus had 
the disorder lasted a long time, to the great discomfiture of the 
physician by whom I was introduced to it, and who, as might 
perhaps be conjectured, liad considered it as an irregular gout. 
As I remarked before, it is probable that some analogous painful 
cases have been noticed by the older authors as coming under 
the Quotidiana or Tertiana arthritica of Sauvages: but it is 
abundantly plain, that this has only happened when a marked 
intermittent has accompanied them, and that, in other instances, 
the same difficulty has been found, or the same errors commit- 
ted, as in our own day. Of this indeed, as to almost every ano- 
malous intermittent, and every Neuralgia which I have enume- 
rated, and even indeed of more, if I am not mistaken, I could 
produce proofs by extracting cases from authors and accompa- 
nying them by an appropriate commentary. Such an addition 
to this essay might indeed be a useful one; but it is plain that, 
to its necessary and natural length, the requisite criticism would 
add so much, as perhaps to cause another volume in a book 
which is already twice as long as I intended and wished. 

TIBIA. 

I formerly took occasion to mention an instance of this va- 
riety; when I also remarked that it had been attributed to a dis- 
eased bone, and that it had been proposed to make an incision 
upon the part to relieve imaginary matter or caries. This is a 
supposition, and a proposal also, which I have met with on more 
occasions than one; as i have further seen such cases treated by 
mercury and by sarsaparilla, under the notion of a syphilitic 
disorder. Th^t this disorder also may thus have been cured, I 
have little doubt, from the occasionally beneficial effects of raer- 



VARIOUS NEURALGIA. 277 

cury in Neuralgia; while it is plain how such a cure would .con- 
firm, by an additional fallacy, the originally false, views of the 
disease. I know not why a Neuralgia, which, in this case, al- 
ways appears to the patient seated in the bone, and which, by 
surgeons, is referred to the periosteum, should occur here above 
many other places where we might equally or preferably ex^ 
pect it; yet many cases of this nature have fallen under my no- 
tice in my own narrow experience. Alternating, in two re- 
markable instances, with the Neuralgia of the head, and occur- 
ring, in two others, in a very marked chronic intermittent, it 
was a variety that could leave no doubt behind, while the truth 
of the views was confirmed by the method of cure. 

If, however, I have here said that I know not how to account 
for a kind of preferable occurrence of the Neuralgia in this part 
of the tibial nerve, its seat being, from the place where I have 
seen it, in some very minute undemonstrable branch, it is a 
question which I cannot well pass over without proposing a sus- 
picion for future investigation when this subject shall be better 
understood. And being a suspicion, I have not chosen to in- 
troduce it into the general account of this disorder, that I might, 
as far as possible, keep all that is fully proved, or what I consi- 
der as demonstrated Truth, free from what, being imperfectly 
proved, might throw a shade of doubt over the surrounding 
portions. This suspicion is; that to a certain extent, nerves are 
more subject to Neuralgia as they approach nearer to the surface 
of the body: and I think that this will appear the fact to him 
who shall consider the cases as they may be collected, or as they 
have here been enumerated. With respect to this disease as it 
occurs in the face, this is very remarkable; and it seems to hold 
very generally, if with exceptions that will not materially de- 
tract from its value as a pathological observation. And if it be 
so, it is not very difficult of explanation: of that general expla- 
nation at least which is as much as can be expected in the pre- 
sent state of our knowledge. It is partly a case depending on 
the same general fact by which it happens that Neuralgia is the 
result of positive injury to a nerve, and partly on the other well 
known fact that it is induced by exposure to cold. Both of these 
particulars are too obvious to need illustration at present: while 
this reasoning will aid in confirming the utility of a remedial 
process derived chiefly from experience, namely, of warm co- 
vering or an avoidance of the impression of cold on those nerves 
which are least protected from it by their situations in the body. 

TOES. 

In one instance I have met with a highly marked case of this 
nature in a toe, arising from, or connected with, an obscuie in- 
termittent accompanying a morbid spleen; and, in another, I 



278 VARIOUS NEURALGIiE. 

have seen a similar one, the produce of external injury. The 
latter, I must reserve to a future place. It is possible, that the 
recollections of many of my readers may enable them to add 
similar cases, not only to this one, but to such others among 
these Neuralgias, as, to myself, have been solitary. In the case 
in question, the pain itself was limited to the very end of the 
toe; but, after some duration, an uneasy sensation, accompanied 
by numbness, extended along the branch and trunk, even into 
the sciatic nerve at the hip; while, even when that extended 
pain had not come on, the patient felt a similar sensation on my 
attempting to trace the course of these with my finger, along 
the surface. The cure of this case proved somewhat difficult, 
though it was at length removed by the means already men- 
tioned; and while for some time it increased in severity, it at 
length happened that the uneasiness and numbness, after reach- 
ing the hip, reappeared in the shoulder, passing down through 
the ulnar nerve, and affecting the end of the finger of the same 
side which corresponded with that toe, or the ring finger. 

RECTUM. 

Of this, one very well marked case has occurred to me; and 
it was one that I had an opportunity of studying very minutely, 
while, for a long time, compelled to maintain my own opinion 
against the universal one of, I may almost say, an army of me- 
dical men, who had, with myself, the opportunity of examining 
it. No one had supposed such a case possible, as, in truth, 
scarcely any one would, at that time, believe in any other Neu- 
ralgia than that of the face: and thus it is that blind habit and 
deficiency in philosophical reasoning form the great obstacle to 
scientific improvement. That the symptoms were attributed to 
organic disease in the part, is what might have been expected: 
while gout was a solution that satisfied those who are always 
glad to find relief in this expedient, and while others, not an un- 
common class, attributed the whole to a morbid imagination: a 
solution which, among medical men, has always been one of the 
readiest cloaks for imbecility and ignorance. How often this 
modification has occurred, I cannot pretend to conjecture; butlcan 
point out at least one other very minutely recorded case, quoted 
in the Bibliotheque des Sciences Medicales, tallying very near- 
ly with that which 1 shall describe. 

This case, however, I must remark, is not so viewed by the 
narrator: being in fact not understood, and being related as a 
mysterious one, as is so common a practice under similar igno- 
rance. It is not therefore described in the best manner; though, 
as it is very minutely detailed, any one, now, after the expla- 
nations of these disorders which I have given, will be enabled 
to see his way through it, and to arrive at the same conclusion; 



VARIOUS NEURALGIA. 279 

as every one, in fact, ought to have done long before, not less 
than the narrator himself; had such persons ever reasoned re- 
specting Neuralgia, or been guided by other rules than those of 
empiricism, whether as to conclusions or practice. And if, 
well known as this work is, and often read as that case must 
have been, no one has arrived at this conclusion, it is a sufficient 
proof, not merely that this particular mode of Neuralgia was 
not suspected, but that no reasoning has ever yet been exerted 
on the subject of that disorder, since it could not have failed to 
attract the attention which I am now directing to it. 

I believe that it will be right here so far to depart from my 
general rule, as to describe the whole progress of this case, yet 
as briefly as possible, as a guide to practitioners; as I conjecture 
that it is by no means a very uncommon disease, and as it may, 
from the intricacy and variety of its symptoms, be really diffi- 
cult to ascertain in some cases, even by a truly observing phy- 
sician. 

At the first attack, and for some weeks, it consisted in an oc- 
casional sensation like a spasm, apparently situated in the ureth- 
ra, about the prostate gland; recurring three or four times a day, 
and causing little uneasiness. Gradually, these sensations in- 
creased in frequency, and were attended with a general sense of 
irritation about the neck of the bladder, very much increased by 
walking, and at length producing spasms in various parts, with 
a tendency to an hysterical paroxysm. No apparent fever of 
any kind was at first present; nor any suspicion of its real na- 
ture entertained; while the disorder, not yet strictly periodical, 
was referred to the urethra and bladder. Very shortly, there 
supervened a debility, with occasional numbness, in one leg; 
and it was easy to trace, by the tingling sensation formerly de- 
scribed, the course of the fibular nerve. At the same time also, 
it was perceived that the mere act of bending the neck forwards, 
brought on the sensation in the perineum, and further, caused 
the patient to totter on the affected leg; a circumstance to which 
I shall have occasion to recur hereafter. 

After enduring some weeks in this form, there supervened a 
febrile state, at first very obscure, but which was, after some 
time, ascertained to be a double quotidian with a nocturnal and 
diurnal paroxysm. Still, the nature and the real seat of the pain 
was obscure; nor was the slightest suspicion of Neuralgia enter- 
tained by the numerous medical attendants who in succession 
examined the case. Such however it appeared to me; and after 
some further progress, every doubt in my mind, if not in that 
of others, was removed by the increased regularity of the dis- 
ease, and by the pain in question becoming as regular as the at- 
tacks of Neuralgia are when most perfect. In this state, the 
first of the quotidian paroxysms was simple, and the second was 



280 VARIOUS NEURALGIA. 

attended by the Neuralgia, which, now increasing in decision, 
increased also in severity. In this aggravated state also, it be- 
came plain that the primary seat of the pain was in the rectum, 
the patient describing it as a burning heat, as from a heated so- 
lid introduced, which was shortly communicated to the bladder, 
producing irritation and strangury. When of this severe na- 
ture, that irritation extended even round the thighs and over 
the lumbar region; so that the slightest touch produced great 
uneasiness, as happens in violent cases of the Neuralgia of the 
face, and was felt even in the abdomen, as if the whole colon 
was affected in a similar manner; which was probably the fact. 

Further, during the severity of the attack, all the limbs were 
affected with spasms; and very generally there supervened a re- 
gular fit of hysteria, with a great degree of general derangement 
throughout the whole system, consisting of the usual symptoms 
of a severe remittent in all their worst forms. Lastly, and not 
to be unnecessarily minute, as the irritation of the bladder ap- 
peared to spread along the ureters to the kidneys, there came on 
diabetes, the diabetes mellitus; while, when this symptom was 
peculiarly severe, it was attended with an acute pain in the left, 
but not in the right kidney, so that possibly this particular symp- 
tom was confined to one of the glands only. And respecting 
this part of the disease, I must further add, that it was rigidly 
paroxysmal, or that the morbid secretion of sugar commenced 
with the general fit, and entirely disappeared in the interval. 

Had I described this case, as cases are usually described, or 
with a more minute and regular detail of the symptoms as they 
actually occurred, it would have appeared infinitely more singu- 
lar and obscure, as it would also have occupied many more pages; 
but viewing it as I have done, I have so classed and described 
the facts, as to render it intelligible, I trust, to any one, even to 
the most obstinate or sceptical. To a spectator, even to a me- 
dical one, it would have appeared still more inexplicable, than 
in even such a detailed description; from the extreme severity 
of the case, rarely perhaps exceeded by any disease in point of 
suffering, and, in particular, from the great distress produced by 
those collateral symptoms, which, as least essential and explana- 
tory, though all belonging to Neuralgia and intermittent, I have 
passed slightly over. And thus, in fact, it did appear to all 
those who saw it with me, and could not contrive to analyze it 
into the same simple form. 

The French case to which I have alluded, is in reality detailed 
in this very manner; so that while the narrator did not under- 
stand it, neither can perhaps his readers in general: as it might 
have been equally obscure to myself, but for the general views 
of Neuralgia which I had already formed. This is a circum- 
stance, I may remark, of perpetual occurrence with respect to 



VARIOUS NEURALGliE. 281 

recorded cases, and especially when of rare or obscure diseases; 
proving how often these might be cleared up by a proper de- 
scription: while in testifying the deficiencies of the recorder, 
they also show the necessity, not merely of medical knowledge, 
but of those analytical and logical habits which are best acquired 
through the study of science in general, both physical and moral, 
and are scarcely to be acquired by any thing short of a wide range 
through the whole of those sciences whence alone the only real 
logic, that which I may venture to call the Logic of Facts, is 
to be attained. Thus must the philosopher, be he even not a 
physician, smile at that opinion, universal as it is, which deter- 
mines that he who cultivates his own profession or science ex- 
clusively, is he who will understand it best, or who will alone 
understand it. As a Science, he will remain ignorant of it to 
the last hour of his existence: in his art, he will be an empiric 
or a trader; nor will he be a successful one, unless indeed as to 
his own ends, since, without the science, the art is helpless. 
And he will leave the world as others have left it before him, 
without adding one iota to the sum of knowledge; the useless, 
and, too generally, the exclusive possessor of facts and oppor- 
tunities which he has been unable to turn to account: the excep- 
tion to those different spirits, who, in universal science, have 
united to bring society out of the animal and savage state to 
what it now is, and one of the exceptions especially, to which 
it is owing that medical science is little other, to this hour, than 
it was in the very infancy of experience. 

Now, lest it might be supposed that my own view of the nature 
of this case was biassed, particularly standing solitary as that did 
against a host, I may enumerate briefly the proofs, with such 
further additions as the progress of the case and the history of 
the patient furnish. 

The person in question had been subject to intermittent, and 
to Neuralgia also, under various forms, habitually, or for a long 
course of years, and this was one of the relapses; a relapse, how- 
ever, which was often afterwards repeated. Under those repeti- 
tions, further, it continued for many years, but with less severity; 
and on no occasion did the period of the attack and the continu- 
ance of the pain vary, by even half an hour, from those first 
established. And moreover, during this long progress, it was 
always attended by its do.ible quotidian fever, and was inter- 
mixed with other neuralgic diseases, while further, re- excited by 
the causes of common intermittent. As to the proofs to be de- 
duced from the history of the case already given, it is scarcely 
necessary to enforce the regular type of the fever, the regular 
recurrence and duration of the pain, the determined length of 
the relapses, always occupying periods of six weeks, the affec- 
tions of other nerves in various places and under various forms, 

36 



$52 VARIOUS KEURALGIiE. 

and the singular regularity of the diabetes which was produced 
by it. I may however add, that the cure of those relapses, or 
the shortening of their duration and the diminution of their se- 
verity, was effected by the remedies which succeed in Neuralgia 
and chronic intermittent, and that the disorder was similarly 
brought back by every debilitating cause. 

From this description, I trust that this particular Neuralgia 
will be now recognised by any practitioner to whom it may oc- 
cur; though it is to be expected that it will vary materially in 
its appearances, as the case in question was probably one of un- 
exampled severity. In every Neuralgia of the simplest cha- 
racter, there are great variations, depending on the severity of 
the pain or local disease, on the force of the accompanying fever 
or its apparent absence, on the nature and regularity of the 
recurrences, and the reverse, and on other particulars which 
it would be superfluous to point out again. This is remarkably 
the case in the periodical headach as I have here described it; 
so much, indeed, that it has been sufficient to prevent practition- 
ers hitherto from seeng that this disease was in reality but a 
mode of the Neuralgia of the face. It is easy therefore to fore- 
see, that in a part so entangled among others asris the organ in 
question, so highly and peculiarly sensible, not only abounding 
in nerves, but those immediately connected with some of the 
most sensible nerves in the whole body, and, as is well known, 
peculiarly susceptible of pain, for obvious reasons, the modes 
and the extent of the pain may be endlessly varied; while the 
sympathetic affections, or the property which this disease has 
of temporarily extending itself to a distance from the part really 
affected may cause appearances or sensations exceeding in variety 
and intricacy all those which occur in all the other Neuralgias 
united. Thus, as I have seen, it may put on, when slight, the 
character of a mere tenesmus, and be referred, as I am very con- 
fident it has often been, to internal hemorrhoids, or to strictures, 
leading to the pernicious and much abused practice of the bougie. 
Thus, too, have I much reason to believe, that such pains have 
been sometimes, perhaps very often, referred to scirrhus: while 
the long duration of Neuralgia when a chronic disorder, would 
still further tend to confirm this erroneous judgment. 

How important it therefore is that physicians should keep 
these facts in their mind in all cases of pains in these parts, it is 
unnecessary to say; since, while the only method of cure is now 
neglected, every pernicious kind of mal-practice may be ex- 
pected: and I have no reason to doubt that when practitioners 
shall be convinced, by the present remarks, of its existence and 
nature, it will prove to be not a very uncommon variety of Neu- 
ralgia. As to the modes of discriminating it, in any case, 
whether obscure or not, I could say nothing that would not be ?. 



VARIOUS NEURALGIJE. £8i> 

repetition of what has so often come before the reader as to the 
whole of the disorders treated in this essay. It will require a 
discriminating observation; but even that must be preceded by a 
just theory, by a conviction of the real nature of the several dis- 
orders here discussed, and by those habits of analogical reason- 
ing which cannot be too strongly inculcated, since, without them, 
all physic must ever be empiricism, and can be nothing better. 
1 have little to add respecting this particular variety, but that 
its seat appears to be in the minutest ramifications of the nerves, 
as in the diffused headach; a conclusion drawn from the simi- 
larly diffused nature of the pain. That, in the case recorded, it 
was spread to such distances, may perhaps be attributed to the 
highly nervous and intricately communicating nature of these 
parts: and with respect to the affections of the larger branches, 
there are parallel cases innumerable in other Neuralgise, of which 
I have described one sufficiently remarkable, in the preceding 
account of this disease in a toe. 

THIGH, 

The only reason for pointing out this situation is, that T may- 
add to the number of the places or nerves which I have myself 
known affected by Neuralgia; as, in the cases which I have seen, 
the disease was remarkably precise with respect to the quality 
of the pain, and exactly resembling the Neuralgia (Tic) of the 
face, in severity and manner. Yet these cases allow me to make 
a remark which was not perhaps sufficiently enforced in treating 
of the Neuralgia of the face. It is, that in this nerve and its im- 
mediate ramifications, in most of the cases which I have seen, 
there was no permanent or moderate and diffused pain, but that 
the whole disorder consisted of those shocks which I formerly 
described, occurring at very irregular intervals throughout the 
day. Thus the physicians who had examined the cases before 
me, could not be convinced of their periodical nature, nor be- 
lieve that they bore any relation to intermittent, or even to Neu- 
ralgia. Yet, in all, the patients had suffered from the chronic 
disease of this nature, while some had also experienced other 
Neuralgias. And further, a careful investigation also showed 
this fact, though it required much cross-examination to elicit it 
from the patient; namely, that however irregular the recurrences 
of the pains were, there was always one portion of the twenty- 
four hours where they never occurred, and that this healthy pe- 
riod was always the same. Thus, in practice, a patient may feel 
one, or two, or twenty, or fifty shocks in the day; but, be the 
number what they may, they belong to a period, which is in 
reality that of the paroxysm, while at least the physiognomical 
mark of the cold fit will be found to forerun them, should no 
©ther criterion of a fever be easilv discernible. 



284 VARIOUS NEURALGLE. 

This happens also, in some cases, in the Neuralgia (Tic) of the 
face; where it has equally led physicians to deny the paroxysmal 
and periodical nature of the disease: an error too the more obsti- 
nate, when, as in all very old and chronic cases, the pains be- 
come so irregular as to occupy only one day or two, and then to 
be absent for a long time. This class of cases has, nevertheless, 
its perfect resemblance in the commonest chronic intermittent; 
where, after a long duration, and in a disease which has, in a 
certain sense, been cured, a single fit will often be brought on 
by some assignable, or some unobserved, exciting cause, appear- 
ing sometimes even in great severity, yet not followed by any 
others. We must consider all these, in Neuralgia and intermit- 
tent fever alike, as cases where the habit alone is no longer a 
sufficient or an accessary cause, and where also, while the appli- 
cation of a fresh one is required, that has no longer the power to 
bring on the whole train which it once did, or to re-establish the 
habit of the disease. 

As the initial term which I have adopted for this division is 
but a popular and lax one, I must now specify anatomically, the 
real seat of the disorder; and if, throughout this chapter, I have 
followed the same loose arrangement, it is chiefly because I had 
not a sufficient number of cases to render it worth my while to 
make an anatomical one: while, moreover, if it would savour 
somewhat of pedantry, (a small pedantry far too common, as if 
any man could not make himself master of the human anatomy 
in a few weeks, as well as of any other tangible and demonstra- 
ble substances;) it would not be a mode of arrangement very 
easily adhered to; since, where the disorder is seated in the 
smaller or minuter ramifications, the most pedantic anatomist 
would be unable to assign its exact claims. 

With respect to the exact seat, therefore, in the cases of this 
variety which I have seen, I must add that it has occurred in 
different individuals, in the anterior crural nerve; in the trunk, 
at the exact flexure of the thigh, and in its ramifications, as low 
as the middle of the limb; in the former case, shooting as sciatica 
does, and with similar severity, down even to the toe. 

In these cases indeed, and in one very remarkably, which, 
under various recurrences and with some neglect on the part 
both of patient and practitioner, united to a deep-seated and in- 
veterate constitutional disease, proved extremely obstinate, last- 
ing, under some vacillations, more than a twelvemonth, the dis- 
order was, in every symptom, a sciatica; only, as might be said 
in vulgar language, in the wrong place. And as the nerve in 
question, at this point, is of a large size, it is easy to comprehend 
how the resemblance should have arisen. And in another of 
these cases, where the disease was similarly at the flexure of the 
thigh, it proved extremely troublesome; recurring during many 



ON SCIATICA. £85 

years, sometimes superseding another Neuralgia, at other times 
accompanying a marked intermittent of no small severity, while 
removed either by the usual remedies, or by change of place, or 
by the supervention of some other mode of the disease. In those 
cases where the pains had occurred at a lower point in the thigh, 
the quality of the pain varied proportionally; while the accom- 
panying circumstances were similar, and the effects of the reme- 
dies also. I have only to add, that while such cases must as- 
suredly have occurred to others as well as myself, I can find no 
account of them; so that those who have seen them must be at 
the trouble of recollecting whether they sought for the solution 
in gout or rheumatism, since they assuredly would not have 
sought it in sciatica. 



KIDNEY 



I have, in another place, described an affection of this gland, 
of a neuralgic character, attended by diabetes. It is awkward to 
separate the present variety, but in the arrangement which I 
have adopted it seemed unavoidable, as it was a case of pure pain, 
apparently in this organ. I have met but with one instance of 
this Neuralgia, or at least of such pain in this precise spot, but I 
shall be surprised if it does not, at some future day, prove suf- 
ficiently common; since superficial observers can so easily ac- 
count for it by gravel, inflammation, or any other convenient 
term. Nothing could be better marked than this case, in all the 
accessory symptoms; that it had been mistaken I need scarcely 
say. I have said, the kidney hesitatingly; because there was no 
increase of urine; no diabetes, as in the other case hereafter no- 
ticed: so that it might possibly have been seated in the trunk of 
the renal nerve without affecting the secretory branches, or, for 
aught that can be known, in the ureter, or even in some other 
nervous branch in this neighbourhood. 



CHAPTER XIII. 



On Sciatica. 



If I have thus terminated a chapter, the limited extent of 
which, as to the heads it includes, is most certainly the conse- 
quence of my want of further experience, since I cannot but sup- 
pose that it will hereafter be far more widely extended, I should 



2S6 ON SCIATICA. 

not have ended it without including in it that subjeet and disease 
which I have reserved for a separate one, since according to my 
own views, it is but a variety under this general species, had I 
not thought it expedient to follow the habitual usages of physic. 
And it is perhaps best thus; while it is in conformity to what I 
have done with respect to some other disorders, and adopted for 
the same reason. It does not appear so utterly to prejudge the 
question: and moreover, it is perhaps a politic proceeding as to 
the wished-for effect: since it will make more impression to see 
sciatica treated with the respect which it has, sometimes at least, 
received from physic, than to have found it amalgamated with a 
variety of disorders which have hitherto attracted little or no 
notice, and which, above all, have not acquired that honour 
which, in physic, is every thing, the honour of being distin- 
guished by a Name. 

It would be superfluous to describe a disorder so well known 
and so often described as this is; being the Neuralgia, above ail 
others, which has attracted the attention of physic, almost from 
the earliest periods. Why it should thus have excited attention, 
may perhaps be explained, from its extreme severity as a painful 
disease, and from the very remarkable place which it occupies. 
And why it has not been considered a Neuralgia, a mere variety 
in an extensive genus of diseases, may perhaps also be, partly at 
least, explained, by its having, in consequence of this conspicuity, 
gained a distinct name for itself. Such is the overwhelming in- 
fluence of terms, in misleading, and in prolonging error; at least 
among those to whom terms are every thing, the substitutes for 
ideas, instead of their representatives. - 

But this is not all; while few disorders afford an ampler proof 
of the laxity of medical reasoning, or rather of the want of scienti- 
fic investigation which has so prevailed in physic, from its infancy 
down to the very hour at which I am writing. This it is that 
has retarded, or rather, impeded, the progress of that science; in 
w r hich we trace little but a succession or a mixture of empiricism 
and hypothesis: while it is with little justice, surely, that phy- 
sicians exclaim against difficulties, thus attempting to justify the 
imperfections of which they complain, or thus desiring to ex- 
cuse their own deficiencies, when they have not applied the in- 
struments and proceedings of science to their art, when, on bad 
observations or imaginary ones, they have engrafted even worse 
reasoning; if indeed they can often prove that they have reasoned 
at all. Universal science might equally have complained of in- 
surmountable difficulties, had its cultivators, in any department, 
acted as Physicians have done: and this day would now see, in 
Astronomy and Chemistry, such progress as physic has made 
since the days of its cradle in the hands of Hippocrates or, 
Galen. 



ON SCIATICA. 287 

And if I have said that this disease offers an illustration of 
what the procedures of Physic as a science have been, it is a sim- 
ple one which all can apprehend, and therefore the more useful: 
while as far as it may include a satire on that science and its 
cultivators, the truth is such as to justify these remarks. And 
if on this one point before us, selected by a mere hazard out of 
the whole Nosology, the investigation and application of a sim- 
ple general principle has elucidated in a moment, (as I trust and 
believe is the fact,) that disorder which has been a standing op- 
probrium to Physic since observation first commenced, then are 
there hopes, that, from similar proceedings, iri future and better 
hands, and as to other portions of this mass of present obscurity, 
other and similar lights will be thrown on other subjects, and 
that at some future day, Physic will be enabled really to take its 
rank among the sciences, with consequences as to human happi- 
ness which it is easy to anticipate. 

To prove that what I have here said is true, I need not surely 
investigate the past history of opinions as to Sciatica, even down 
to the days of Cullen (and later J need not note those) since that 
is well known to all my readers. He, like others, ranks it with 
Rheumatism; and I select him, not to censure hi??i, but because, 
as a systematic writer, a public teacher, and a recent author, he 
is the representative of Medical opinions. Why was it ranked 
with Rheumatism? because it was a painful disorder: such are 
the reasoning processes of physic, yet it complains of difficulties. 
And what is Rheumatism? a painful disease also; "a peculiar 
affection," says Cullen, "of the muscular fibres, with an inflam- 
matory disposition in the system at large." 

If by such a road, sciatica was to be investigated, if this is the 
road by which physic proceeds, as it has proceeded, have we 
any reason to be surprised that this disease remained unknown, 
and that physic is what we find it? not merely that Neuralgia 
remained to be investigated to this hour. It is pardonable to 
feel indignant w 7 hen the science to which we have especially at- 
tached ourselves is thus treated, and still more, when we reflect 
on the consequences of such a procedure. And even when the 
author whom I have cited as the organ of opinions does thus 
class this disorder, he passes it over as if unworthy of regard, 
proving further that he looked on it but as a variety; while the 
universal practice, common to this with all rheumatism, proves 
that this also was the general opinion, even had that not been 
otherwise capable of proof. 

Yet it was discovered, and long ago, by some observers of 
more acuteness, that sciatica was seated in the nerve, at least 
occasionally. This however led to no results, far less to that 
generalization which it ought long since to have done: and how 
little it effected, is still proved by the same high authority, when 



288 ON SCIATICA. 

he treats with neglect the opinion and its author. And still, if 
that opinion has recently spread, if, as was long ago obvious, as 
ought always to have been plain, the nerve is always the seat, 
and the true seat, of this pain, if it is in no sense a rheumatism 
as that disorder has always been apprehended, (though, if in 
some measure classed with it under the present views, it is so 
under entirely new ones,) no general law has been laid down 
respecting it, nor has it been viewed as what it truly is, the 
Neuralgia, or, to use this popular term, the Tic doloureux in the 
sciatic nerve. Yet such it is, and such its theory and its place in 
the system. 

Let us now reverse the case, and see how, while its theory 
has been derived from the Neuralgia of the face, the theory of 
this, and indeed the whole theory of Neuralgia, ought long since 
to have been derived from sciatica. Had it been seen, even by 
Cullen, that it was a disease of the nerve alone, that it was a 
Neuralgia, and had it been merely inferred or suspected that, if 
one nerve could be thus diseased so might another, had the very 
simplest process of reasoning been adopted to conclude that any 
nerve might be affected as the sciatic nerve is in this case, or had 
the disorder been made generic instead of special, and had, still 
further, the term Neuralgia, or any term, been applied to it as a 
general and generic one, it is scarcely possible but that the whole 
of the Neuralgias should long ere now have taken that place in 
a nosology which is so amply their due, and which it is so im- 
portant that they should at length possess. 

Or, to make this remark more simply, if sciatica has been 
ranked as a variety of rheumatism, it is but one instance of many, 
of that laxity which I have been censuring; influencing, not 
merely ordinary observers, but nosologists under the professed 
guidance of philosophy and logic; a laxity which, satisfied with 
a symptom, neglected to inquire of causes; and to which, even 
pain, the least characteristic of all symptoms, was evidence 
enough of similarity or identity. And if it is true that a few bet- 
ter observers had determined that the seat of the pain was, in 
this case, the nerve itself, and not, as in rheumatism and its ana- 
logies, the muscular or membranous parts, that conviction has 
not been solid, or rather, is not so universally solid and complete 
as it ought to be, even at this day, while it is not general, in any 
mode. And if this assertion were doubted, the proof would be 
found in the nature of the practice in this disorder, and in the 
complete wavering or laxity by which it is characterized, even 
in the hands of those who feel a sort of belief, I cannot call it 
a conviction, that the nerve itself is the real seat of the disease. 

Undoubtedly, when I look into ancient and foreign authors, 
I find occasional notices of sciatica attending intermittent fever 
or following it, and of the same disease having periodical re- 



ON SCIATICA. 289 

turns with or without intermittent; as I even find cases, for one 
of which I may quote Werlhoff, where bark had been adminis- 
tered successfully, and on those very grounds. But I cannot 
discover that these have been considered as aught but incidental 
facts; nor, even when the disorder is referred to the nerve itself, 
that it has been viewed as a real Neuralgia, still less that it has 
been ever treated, otherwise than experimentally or empirically, 
by the remedies of that disease. I need scarcely refer to the 
systematic writers for the proof of this, when Cullen hardly 
condescends, as I have just remarked, to notice the sciatica, 
even when he treats of it under rheumatism, and when he al- 
most seems to sneer at Cotunnius for his opinions respecting an 
Ischias nervosa. 

But if it is time to terminate a criticism on what is past, I 
must persist in thinking that such criticism is not only justifiable, 
but necessary and useful; while it is in reality a criticism on the 
science itself, or, if on its cultivators, on those as impersonal be- 
ings, or philosophical and abstract entities, not as individuals 
who have lived or may now be alive. Science and its history 
cannot be examined, for good or evil, without a reference to 
those agents by whom, for good or evil, it is pursued; but if, 
when we have to allot praise, we gladly identify the Ens with 
the Titius or Marcus by whom it has been merited, we as gladly 
suppress, reversely, the names of those by whom it has not been 
deserved, as far as that can be attained. Unfortunately, howe- 
ver, where no individual is selected for blame, all feel it as if it 
were directed to themselves; while an unfortunate sensitiveness 
on the part of those who profess physic, arising obviously from 
its trading quality, renders this impression much more general, 
and, as to the critic, much more disagreeable, than it would be 
in any case where deficiency in science did not also imply a de- 
ficiency in the right or claims to profit; or, as it is felt, tend to 
produce some hazard of failure or diminution in this essential 
point. 

To proceed with the history of the disease as far as I need 
enter on it: while the characters of sciatica show that it is one 
of the Neuralgias, so does it prove to be the most severe of its 
tribe. It is in fact so like to the variety last described in parti- 
cular, even in its situation, that it is a matter of wonder how 
its' real place and nature were not determined from the very 
commencement; unless indeed the similar affection of that nerve 
had escaped notice altogether, which is scarcely possible. That 
its analogy to the Neuralgia of the face, or the analogy, re- 
versely, of that Neuralgia to sciatica, was not long ago seen, 
can be accounted for, as I have said, only by that oversight or 
ignorance which could suppose the place of a pain sufficient to 
constitute a disease, and a genus, or species. That the opinion 

37 



290 ON SCIATICA. 



which I would here confirm, has however been entertained late 
ly by a few individuals, I have already admitted; but as long as 
the entire theory of Neuralgia remains unknown, while the 
whole of these diseases are not generalized under one leading 
principle, so to believe is only to add one empirical fact to ano- 
ther, without making any real progress in knowledge. And 
moreover, while cases of Neuralgia are often conceived to con- 
sist in inflammation of the nerve, using that term in its ordina- 
ry sense, the effect is as bad as the theory is unfounded, since it 
can only lead to wrong practice; while it is sufficient to examine 
the present practice, even in proceeding on that somewhat im- 
proved view, to be convinced that nothing has been gained; as 
is the inevitable consequence where a theory is imperfect, or, as 
in this case, still false, inasmuch as it is imperfect. 

It is on this view of its nature, that we can explain the pecu- 
liar intensity of the pain; a pain, both for quality and violence, 
bearing no resemblance to that of rheumatism. On this view 
also, we can explain its confined nature, the absence of inflam- 
mation, the state of diffused irritation about the parts which at- 
tends the fit of pain, the shocks which accompany it, resem- 
bling those of ail the Neuralgias, and its propagation along the 
course of the nerve. And if these peculiarities are thus ex- 
plained, so are they the proofs of its real nature; while similar 
and further proofs are found in the paralytic affection which so 
often follows it, and which, as 1 have already shown and shall 
more fully show hereafter, is a frequent consequence in all 
Neuralgias, particularly under bad or wrong treatment. If 
spasms in the adjoining muscles, or throughout the body in 
general occur in sciatica, so do they in all the Neuralgias; and 
it is further remarkable that it produces, in irritable habits espe- 
cially, hysterical symptoms, as do the other disorders of this 
nature, together with a general irritability, both of mind and 
body, which seems to belong peculiarly to the painful diseases 
of this nature. 

It is further remarked that the pain of sciatica " breaks down 
the constitution;" or that there is a state of general disorder, in 
the chronic cases especially, which is scarcely produced by any 
chronic painful disease, not even by gout and stone. This is 
the condition or change to which I formerly alluded and shall 
have occasion to allude again, and the cause of which I then ex- 
plained; a condition which attends all the Neuralgias without 
exception, when of long continuance. If other proofs of simi- 
larity or identity were required, they would be found in its in- 
veterate duration when once established, an inveteracy which 
has rendered it an incurable disease; in the inutility or the 
mischievous effects of blood-letting and local applications; in its 
apparently voluntary cessation on change of place or of habits. 



. 



ON SCIATICA, 291 

and in other circumstances, attending the remedies for good and 
evil, which I need not again repeat, often as they have been dis- 
cussed for the parallel cases. 

It will be objected by those who are averse to this view of 
Sciatica, that it is not so strictly periodical as this theory would 
demand. I believe that this objection can be satisfactorily an- 
swered, on the grounds already so often stated as to all the Neu- 
ralgias; and further, that whoever shall commence by believing 
this theory to be true, or even supposing that it is possibly so, 
will be at no loss in confirming it by observation. Sciatica has 
not been supposed an intermittent disease, and therefore its pa- 
roxysms have not been sought for: while their obscurity, or im- 
perfections, already accounted for in all the Neuralgias, have 
countenanced that prejudice or carelessness which so pervades 
all practice, in that which is a trade, in reality, much more than 
it is a Science. 

But in fact this regularity is not only a very common occur- 
rence, but as I commenced by remarking, there are many cases 
of rigidly periodical and intermittent sciatica on record, of which 
there is at least one familiarly known, in the Edinburgh Medi- 
cal Essays. And when I further find that even an acute medi- 
cal friend, residing where this disorder is endemic, now con- 
stantly observes this character, which, till it was pointed out to 
him, he had overlooked, or in fact had never once perceived, 
when he now seldom fails to discover also the intermittent fe^ 
ver, even regular, when he finds it to connect itself, as to the 
place of its endemic occurrence, with Neuralgia of the face, 
sometimes also occurring together with that in the same patient; 
when further he writes to me, that since he adopted arsenic at 
my suggestion he seldom fails to cure it, and lastly, when we 
know that in the ancient cases, change of place or air is the best 
remedy, I can scarcely believe but that when these opinions shall 
become more universally spread, I shall see the same testimonies 
from many other quarters, and that this most painful disorder 
will no longer be that opprobrium to physic which it so long 
has been. 

In fact, if the absolute paroxysmal and intermittent character 
of Sciatica is not frequent, it seldom happens that a distinct 
exacerbation is not to be found; while this is generally over- 
looked, in consequence of the very vulgar philosophy of the 
patient's " becoming worse when he is warm in bed." That is 
to say, this is a nocturnal paroxysm: and when he is not 
" worse in bed," as happens not less often, the paroxysm is di- 
urnal. But it would be mere repetition to explain all these va- 
riations or anomalies; since whatever I have said on that head 
respecting Neuralgias and also intermittent, belongs equally to 
Sciatica, and can be explained on the very same grounds. And 



292 ON SCIATICA. 

thus also is it explained, how the disease varies in its mode, ap- 
pearances, or intensity, as it is recent or habitual, acute or chro- 
nic; as we equally explain how it occurs in relapses of a certain 
duration, with intervals, and how, in old cases, single fits will 
be brought on by an occasional cause; all of them facts occur- 
ring in intermittents and in Neuralgias, under the same circum- 
stances. 

I know not what fortune others may have had as to this dis- 
ease, though I am inclined to suspect, that, from being solely 
occupied by the pain and prepossessed with a wrong notion of 
Its nature, practitioners in general have neglected what I have 
never failed to find, namely the intermittent febrile paroxysm, 
under all the characters or variations which attend it in Neural- 
gia in general. And I believe that this may always be found 
when it is sought; provided of course that the physician has the 
means, or makes the opportunity, of watching the disease as it 
ought to be watched for this purpose. 

Thus does it appear to me that the character of sciatica is per- 
fectly established as a Neuralgia, or as coming under the divi- 
sion of local or neuralgic Intermittent; and how important this 
view is, as to the practice in this disorder, a practice which has 
hitherto disgraced physic by its failures, I need not say. I do 
not mean at the same time to assert, what in fact I do not sup- 
pose, that it is necessarily the produce of Malaria; because I 
have already shown that the other Neuralgias appear to arise of- 
ten from simpler causes, and are assuredly the produce of even 
local injury in some cases. If in attempting to ascertain what 
the common nature of any diseases may be, or in arranging any 
number of varieties under one common genus, or even one com- 
mon proximate cause, we are to be called upon to find a com- 
mon remote or exciting cause, this is not the only case, by many, 
in which we should have to dispute our way through nosologi- 
cal arrangements. Even simple intermittent may, for aught 
that we yet know, have more causes than Malaria, and it is, 
perhaps, even probable that it has; and thus may the Neuralgias, 
and the sciatica among them, be the produce of mere cold or 
damp, as the latter disease has been commonly supposed to be. 

But let me add a word on this point, since I may as well pro- 
vide for the criticisms to come, by showing that I know them 
already, by anticipation, and that, whatever they may be, I 
have considered their value, and have not written one line with- 
out keeping them always in my view. This is at least suffi- 
cient to prove that I do not consider them available; and 1 may 
as well therefore answer this one now as hereafter. It is said, 
that, from the habit of contemplating Malaria, I see in it the 
cause of more diseases than it does or can produce. The an- 
swer is, that the evidence is adduced j and upon aa investigation. 



ON SCIATICA. 293 

of the value of that evidence must others decide, as I have done. 
Let them so decide, after proving that the evidence is insuffi- 
cient; and having thus proved that I am not right, it shall be 
admitted: but to all conclusions that do not derive from the exa- 
mination of evidence, he who is accustomed to guide himself 
by that, turns a deaf ear. When electricity became first known, 
its early cultivators held it forth as the solution for all physical 
difficulties, as the cause of all phenomena. This was an induc- 
tion before evidence, and they were ridiculed. That probably 
would have happened had there even been evidence, supposing 
it imperfect. Yet it has now been proved that this power is 
deeply concerned in chemical composition, in magnetism, in 
meteorology; and the day is probably not very distant when the 
anticipations will be fulfilled, and the ridicule become a subject 
of shame. 

But, to return, while a good deal has been proved, I have 
not the slightest desire to assume more: and the truth is, that if 
we have much yet to learn on this subject, we must not suffer 
our ignorance in one or two points to become an excuse for per- 
severing in ignorance or obstinacy as to others, where know- 
ledge, a modified knowledge, which is better than none at all, is 
attainable. To have ascertained the generic community or ana- 
logy between any number of diseases, is useful knowledge; to 
have ascertained that the proximate cause of these is a common 
one, is also useful knowledge, though we may not be able to 
define what that pathological condition is; and if the remoter 
causes, or the circumstances which induce that pathological con- 
dition are but partially known, it is, even then, a step in know- 
ledge: but it would be highly presumptuous to suppose that these 
were exclusive, greatly ignorant as we are in all the philosophy 
of this most intricate branch of natural history; nor do I desire 
to assign to Malaria one title more of power in this respect than 
it shall be proved to possess. 

If it is not my design to pursue further the history of a dis- 
order so well known, when my only object was to produce the 
proofs of its belonging to the class of diseases under considera- 
tion, there is one fact respecting sciatica which seems well as- 
certained, and which, if it leads to no conclusion now, may be- 
come of use hereafter when this class of disorders shall have been 
better understood and studied. It is observed to be peculiar, in 
a general way, to certain situations, or to be a sort of endemic, 
in those, while little known in others; and thus for example, it 
is extremely common in Cumberland and Westmoreland, among 
the peasantry. It is a singular analogy to this, that, in a cer- 
tain district in Wales, the Neuralgia of the face should be the 
common form of the disease, while the sciatica is, comparative- 
ly, little known; but how much further such facts may extend. 



294 ON SCIATICA. 

we have as yet no information; and for the plain reason, that 
We have had no observers and no philosophy. I do not pretend 
even to imagine a cause; but, if it is of any value, or rather if 
it may' be ultimately of any value when our knowledge of 
these diseases shall become more extensive, there is something 
similar to this in the common intermittent, as I formerly ob- 
served; since there are certain situations which produce quoti- 
dian, or tertian, or quartan, in preference, respectively, to the 
other forms. And if what I have attempted to prove in ano- 
ther place be true, namely that the enlargement of the Thyroid 
gland is caused especially by the Malaria of alpine valleys, here 
is another fact and an analogy, seeming to prove that there are 
distinct modes of Malaria productive of distinct disorders: facts 
which even insulated and obscure as they may be, we have no 
right to reject, any more than the limitations of the range of 
Malaria, merely because we cannot explain them. To make 
our ignorance the measure of truth, is to establish a philosophy 
which had it existed at the beginning of the world, would have 
now found us on a level with the animal men of New Holland. 
A much larger collection of observations may possibly hereaf- 
ter throw light, not only on the causes of these variations, but 
on the nature of Malaria in general: but the subject must be 
pursued in a far other manner, and I fear, by other persons, than 
it has yet been. 

As to the cure of sciatica, I might here, it is true, discuss the 
practices recommended in medical books, and consider how far 
they are useful or mischievous; as I should have done, had this 
been intended for a full history of a distinct disease. But as the 
greater part of such an examination must be necessarily entered 
on in treating of the cure of Neuralgias in general, the conse- 
quence would be a repetition which ought to be avoided; while 
it will be easy, should it in reality prove necessary, in this, as 
in other local cases, to make such particular allusions under the 
head of the general cure, as each specific variety may demand. 



[ 295 ] 



CHAPTER XIV. 



On Questionable JYenralgice. 

I have now gone through all those Neuralgias, or affections 
of nerves, consisting of pure pain without inflammation, and 
produced without external injury, which have come under my 
own observations, with the exception of toothach; which I am 
compelled to defer to a later section, from unwillingness to se- 
parate the cases of this nature from those where the cause can 
be traced to local injury; thus making two divisions of a disease 
so familiar and so long known by one term. 

But I have still to notice some painful affections which may 
throw light on this disease, or may be assignable to the same 
cause: while the remarks are offered only as suggestions for fu- 
ture inquiry; being facts which, from their rarity and obscurity, 
and from their doubtful nature, or from the imperfection of their 
evidences, I could not place in the former list, and do not choose 
to pass entirely over. I feel no ambition to overstep, even by 
a hair's breadth, the bounds of evidence; having never disco- 
vered that either pleasure could, or fame ought to accrue from 
the talent of invention in matters of philosophy, or from applying 
the imagination to what belongs to the province of cold reason. 

I had occasion formerly to suggest that lumbago might often 
be a neuralgic pain; though perfectly ready to believe that it is 
also a rheumatic affection, in the usual sense of that term; while 
I related an instance of its alternating with the common Neural- 
gia of the face, which could leave no doubt on that subject. 
There appears no reason to question the possibility at least of 
this, as a matter of theory; considering the nervous anatomy of 
that part of the body, and analogous cases in which it has been 
proved that the pain of Neuralgia exists over a great space, and 
in a comparatively mild form, from being seated in the minute 
ramifications of the nerves. But whatever may be judged of this 
opinion, I have met with cases where it was impossible to enter- 
tain a doubt; from its occurring as a transient and periodical, 
though severe pain, alternating with other neuralgic disorders, 
and in a patient suffering under habitual intermittent. Whether 
that pain of the loins occurring in fevers is not an affection of the 
same nature, is a question formerly noticed, rather of curiosity 
than use indeed, which may remain for future consideration. 



296 QUESTIONABLE NEURALGIA, 

There is a well known pain of the stomach, which has ob- 
tained no name as a disease, common as it is, unless the term 
Gastrodynia may suit it: and which therefore I know not how 
to describe, otherwise than by saying that it resembles the par- 
ticular pain produced by honey, in those persons with whom 
this substance disagrees, It is enumerated among the nervous* 
symptoms, in authors who have treated of this subject, and 
among those of dyspepsia; but it is very certain that it often oc- 
curs where no dyspepsia is present. The most remarkable par- 
ticular connected with it is, that it is very generally chronic, or 
that persons once materially subject to it are also subject to re- 
currences; that it comes on without apparent causes, or at least 
without the use of improper food; that it is scarcely relieved by 
any remedies, rather holding on its natural course, and, where- 
ever it is habitual, lasts a definite number of hours. In these 
particulars, it appears to have an affinity to the Neuralgia?, 
though I should scarcely have thought of suggesting this possi- 
bility, had I not known one case where it did occur in a patient 
subject to chronic intermittent, and did replace, repeatedly, 
another decided Neuralgia, in alternations more or less regular; 
while it also maintained the same exact periods of recurrence 
and duration. 

And when, in another case, and that in a young person, I 
knew it to continue for three years, returning regularly at three 
o'clock in the morning and lasting two hours, yet, during this 
long period, occasionally ceasing for a week or two, as chronic 
intermittent or Neuralgia does, while also invariably removed for 
a time by change of place, and when this patient, before that 
time, and after it, had suffered from quotidian ague, and from 
quotidian toothach, also recurring at that same precise hour, I 
really know T not to what other solution I can resort, though I 
willingly leave that to any one who can give a more rational 
explanation But I gladly indeed leave this obscure disorder as 
a subject for future inquiry; becoming more timid the further I 
proceed. 

I have just read, in a recent foreign journal, (French,) a re- 
ported case of inflammation of the spinal marrow. It is very ill 
reported, as it appears to have been ill observed; and I entertain 
little doubt that it was a case of Neuralgia, under some of those 
modifications, the nature of which must regain a mystery as long 
as we continue ignorant of the real, pathological, change which 
the nerve undergoes in these disorders. To suppose indeed that 
the whole body of this great nerve could be affected to the de- 
gree in which the sciatic nerve is in sciatica, would be to sup- 
pose a disease which we should probably have little opportunity 
of studying, and which has, probably also, never occurred. But 
it is easy to imagine a minor degree of the same disturbance or 



CiUESTIONABLE NEURALGIA. 297 

derangement, capable of producing all the symptoms described 
in the case in question; while any misrepresentation, should 
such exist in that, or in any other cases, would be easily ex- 
plained by the practitioner's absorbing or fashionable theory 
respecting inflammation, and still more respecting its remedies, 
and by his ignorance as to the nature and extent of Neuralgia. 
And that such a disease actually does exist, is proved by that 
case of the Neuralgia of the rectum already related; in which the 
affection of the spinal marrow was unquestionably situated near 
its origin, or extended so far; while it is quite easy to imagine a 
greater degree of the same disorder in this primary nerve, and 
without the presence of such local affection as this. That, in the 
case in question, this great nerve was really affected in some 
local manner, and at the point just mentioned, was proved by the 
consequences produced on bending the neck; of which, the in- 
stant result was a sudden irritation in the perineum and bladder, 
with a loss of power in the legs, and chiefly in the left, (of which 
one nerve was particularly affected,) so great as to cause the pa- 
tient to stagger and to be in imminent danger of falling. 

Such cases are probably very rare; and yet we can never 
know what is rare or common, till it has been described: since, 
through all nature, every thing, every substance, has been once 
rare, as, once, it was not supposed to exist; while the effect of 
description is to render it, very generally, common, sometimes 
even to familiarity. Chemistry and mineralogy abound with 
proofs of this fact; and I formerly insinuated, that, in the very 
subject under review, the same has been true of Neuralgia. And 
in physic generally, it is a mere dogma that the lower classes 
and the savage or unimproved tribes of mankind are subject to 
fewer diseases than the reverse divisions; while it has seldom 
been asked whether, in such instances, there are observers pre- 
sent to note the disorders that do occur. If luxury and physi- 
cians are accused of making diseases, it is not for me absolutely 
to deny the assertion: but the greater truth would be, that the 
diseases of the opulent and the cultivated seek for attention and 
find observers. 

But to pass from these general remarks, should record, exam- 
ple, fashion, or what not, render a belief in the inflammation of 
the spinal marrow, described by the French author in question, 
general, and symptoms occur to justify the presumed presence 
of such a disease, the facts which I have here stated and the 
suggestions which I have made, will be of some value; because 
it is probable that the importance of the affected part would lead 
to a partially active interference of that system of imagined re- 
medy, evacuation, which, in all these cases, is as fatal as it is ac- 
tive, and which is destructive in proportion to its activity. 

Yet I cannot quit this subject without reminding the reader, 

* 38 



298 QUESTIONABLE NEUKALGIA. 

that the same theory and the same term have been applied to the 
ordinary Neuralgia of nerves; guiding also the practice, and, as 
I have remarked where I noticed that fact hereafter, misguiding 
it. The one case, as I there observe, illustrates the other: and 
it is not difficult to see how extensively evil would follow from 
the adoption of such a general theory, as partial evils inevitably 
must, whenever a nerve, thus pained or affected, is presumed to 
be in a state of ordinary inflammation. That the condition of 
the nerve during the painful stage does resemble that of inflam- 
mation, I have fully shown: but it has equally been shown also, 
that it requires a very different set of remedies from those by 
which this general affection, in its ordinary sense, is van- 
quished. 

It is rather a matter of curiosity than use, to suggest that the 
acute, sudden and transitory pains so well known, as occurring 
in various parts of the body, are Neuralgic, whatever their 
causes may be. As far as sensation can decide such a question., 
those who have felt any of the pains of a real Neuralgia, will 
at least pronounce that such flying pains have the same seat, or 
are situated in a nerve; and if it can add any thing to this sup- 
position, those pains will be found to occur frequently in per- 
sons who have been subject to Neuralgia, particularly when that 
has affected more nerves than one. 

To add to these doubtful or yet unascertained cases, if I have 
found many more records of painful and unexplained diseases 
than I choose to quote as probable instances of Neuralgia, there 
is one that I cannot pass over, though I cannot prove my sus- 
picion to be well founded. This is the ear-ach, or otalgia of 
systematic writers, abounding in some cases which are marvel- 
lous and more which are obscure: while when durable and other- 
wise inexplicable, they are often attributed to worms or insects 
in the ear, whether these could be extracted and proved or not; 
just as the Neuralgise of the face have been so often assigned to 
similar causes in the frontal or other cavities, 

I may however terminate these suggestions as to what I have 
termed questionable Neuralgiae. If they are of little practical 
importance, if even, as mere speculations of theorj^, they should 
be thought unfounded, they will not be without their use. I 
wish it to be clearly understood, that I am very far indeed from 
supposing that I have enumerated all, perhaps not one-tenth, of 
the nerves or places where even a definite Neuralgia may occur, 
and far less all the troublesome or obscure forms which these 
disorders may put on. It was a new subject when I undertook 
it; and if it is now admitted that Neuralgia is found in many 
other nerves than those of the face, the perpetual occurrence in 
authors, of cases of this nature, represented as mysterious or ex- 
plained on some other grounds, together with the very limited 



QUESTIONABLE NEURALGIA. 299 

number of practitioners out of the whole mass who seem to be 
aware of it, prove that such knowledge, even to this moderate 
extent, is as yet very little diffused. This investigation there- 
fore, imperfect as it may be, has been a contest with difficulties, 
and with what is much more painful, opinions, and prejudices. 
What has been even more productive of obstruction, it has been 
cramped by limited opportunities of personal observation, and 
by that perpetual source of vexation to him who is in pursuit of 
truth, the difficulty of understanding, or of extracting that truth 
from recorded cases, where the narrator, with even the best 
faith, has viewed them under a prejudice or a false theory. To 
have suggested therefore the possible cases of this disorder which 
I have noticed in this section, will probably lead others to look 
back on what I may have actually demonstrated, as a mere 
sketch, a work barely commenced to establish, further, the prin- 
ciples and leading facts in their minds, and keeping them steadi- 
ly in view, to apply them to the solution of such difficult cases 
of painful or peculiar diseases as may occur in their practice, or 
to those disorders where error as to the real nature is possible, 
and where that error would lead to serious evil consequences. 

Of cases which have not occurred to myself, of Neuralgiaein 
other parts of the body than the face, I find only the few fol- 
lowing noticed by different authors: but I could probably have 
increased the list, had I chosen to search more widely, or ven- 
tured to explain in this manner, peculiar cases of painful dis- 
eases which the narrators had not understood. The latter is a 
hazardous, and not always a very just proceeding: and I know 
not, that, to have extended the list in this manner, would have 
been of any advantage, when I have shown that this disease 
may occur any where, and when I have drawn from my own 
observations what, I trust, will prove satisfactory on this point. 
To have introduced disputable cases, might have tended to throw 
discredit on what is proved. 

Dr. Alderson relates a case where one breast (mamma) was 
so affected; and there is one in Swan, where the disorder is 
said to have been seated in the second cervical nerve, extending 
to the ear and face. A case of Dr. Pearson's, where the thumb 
was affected, scarcely differs from those occurring in my own 
practice, in the fingers. 

Among cases described by authors, similar to those which I 
have myself observed, I shall be content with naming the fol- 
lowing. In the thigh and leg by Hall; in the arm by Pearson 
and by Swan, in a finger by Abernethy; and in the leg and 
thigh by Yeatts: while I cannot help remarking that so confined 
a record of such cases from so many persons in extensive prac- 
tice, and from others who have written, even exclusively, on 
this disorder, compared to those which have occurred to myseli) 



300 » QUESTIONABLE NEURALGIA. 

in a very confined range, will almost prove that the Neuralgia 
under these forms has been misunderstood, or mistaken for other 
disorders, as, from many other cases of peculiar affections, is 
most evident: and most probably for want of just views respect- 
ing the nature of this disease. 

Nor ought I to pass from those remarks on the cases which I 
have thus borrowed, without an observation which, if in some 
degree made before, is really so important as it concerns the 
present attempt to establish this disease, Neuralgia, as meriting 
a distinguished and generic place in nosology, that it requires to 
be made more pointedly. That it is impossible but that it should 
have always existed, seems too plain to require proof; while 
what I have already brought forward in evidence does in reality 
prove that to have been the case. Yet if we except sciatica, 
known from the earliest times, the very modern notice of An- 
dre is the first account of a variety no less conspicuous and pain- 
ful; while from the moment of its announcement, it has been 
discovered to be a very common disorder; unknown, or rather, 
unmarked as it had been before. Still, if we except this parti- 
cular variety, it is but within a few years that any others have 
been noticed, or even suspected; while Cullen, though following 
Sauvages, who had thus far borrowed from Andre, takes no no- 
tice whatever even of that one in his System of Practice. And 
in foreign writings, systematical or otherwise, universally, if 
we can find cases which may thus be interpreted, we see clearly, 
that while related as obscure diseases, none but such marked 
cases have been selected, and so selected because they were ob- 
scure; though it is certain that, in particular, in the pestiferous 
districts of France and Italy, as elsewhere, they must be com- 
mon: common as in India and Persia, where also they would 
never have been noticed but for the publications on this disorder 
of the Face. And what has been true, is still true. The Neu- 
ralgia of the face is indeed so far rescued from obscurity; but 
the work was but commenced, as long as its connexions and 
nature remained unknown, or while its theory was groundless, 
false, or obscure. But all else, all that concerns other varieties, 
remains as obscure as before; and the proof has been just given, 
as indeed it has appeared throughout: since, had it been other- 
wise, I should have been able to adduce hundreds of cases in 
the place of three or four which I have with difficulty found. 

What then must have been the mass of suffering? and all for 
want of a name and a place: for want of the definition and ex- 
planation of a common disease, neglected because it was not de- 
scribed, maltreated because not understood. Let others now 
draw the conclusion which I need not, as to the present attempt - 9 
and be convinced, that, in physic as in all else, nothing is known 
to exist till it has been described and received a name. 



QUESTIONABLE NEURALGIA. 301 

I have now a few general remarks to add respecting these 
painful or proper Neuralgias, which could not well find a place 
sooner in this form, if some of them have been incidentally an- 
ticipated. 

If I mentioned that this disease might be acute, or transitory, 
or else chronic, or habitual, it is a fact that requires to be stated 
somewhat more fully. I do not know from experience that, in 
a new case, or in a patient who has never suffered before, either 
from Neuralgia or intermittent, a disease of this nature is ever 
so transitory as to last but one day, or to form but a single pa- 
roxysm. But in the reverse cases, it frequently happens that a 
complete and severe attack of Neuralgia, in a nerve never be- 
fore affected, will come on and disappear, perhaps for ever, after 
one paroxysm; and also withont remedies. I believe that this 
fact has frequently been overlooked, as an accident and not wor- 
thy of notice; as every thing is an accident in all science to 
those who have not the requisite knowledge for generalization. 
This is a case which has frequently occurred within my own ex- 
perience, and in many important nerves: as in the maxillary, 
forming the common Tic, in the sciatic, in the femoral, in the 
fingers, in the optic nerve, in the testicle, and elsewhere. 

Perhaps this may be viewed as the next stage from those fly- 
ing pains, appearing but once, and for a moment, which I have 
but just noticed; while, in further stages, the same diseases may 
last two or three days, or even weeks, still disappearing in the 
same inexplicable manner. And while I believe that such cases 
are far more numerous than is commonly imagined, particularly 
among the lower classes, naturally not so ready as their betters 
to apply for advice, I also imagine that it is partly owing to our 
neglect of them that this disease has so long remained unknown 
or misunderstood. 

It is in its chronic or durable state, that, even as the mistaken 
disease which it is under the name of Tic, it is best known: 
and, as a chronic disease, there seems no end to its duration, 
since, like intermittent, it is often the inheritance of life. Yet 
in these extremely durable cases also, it loses its regularity, often 
so completely, that no traces of that can be discovered: a further 
cause, as I formerly observed, of the errors or obstinacy re- 
specting its real nature. And thus chronic, or perpetual, it may 
become under any one of its forms; as it is vulgarly known to 
be, not merely in the Tic, but in sciatica. 

Lastly, when a patient has suffered completely from chronic 
intermittent, and has also experienced Neuralgia, particularly 
should he have had it in more than one nerve, it sometimes hap- 
pens that he will suffer from it in a great number, or may exhi- 
bit the greater proportion of the varieties which have here been 
enumerated: and, further, those that arc to follow: and not only 



302 NEURALGIA OF GLANDS. 

so, but also the anomalous intermittents described in a former 
part of this essay. In such cases, it would seem as if the whole 
Nervous system, or the greater part of it, was affected or de- 
ranged; actually diseased in parts, or, from some general ob- 
scure condition of irritability unknown to us, rendered highly 
susceptible of becoming so, and thus of producing a Neuralgia 
wherever any collateral cause may act at the same time. 



CHAPTER XY 



On Neuralgic Affections of the Glands, 

I have been able to preserve so little order in this essay, from 
the plan which I have found it expedient to adopt in conformity 
to popular opinions, that it is indifferent where I introduce the pre- 
sent section. Nor, in truth, have I any new affections to no- 
tice under this head; having already taken occasion to name 
those which have occurred in my experience. The subject is 
however an object of scientific interest at least, as it relates to 
the theory of these disorders; while it is not even impossible 
that it may prove one of practical utility, as I shall presently 
show. 

I have recently pointed out the flow of tears and the saliva- 
tion which frequently occur in the Neuralgia of the face; and 
they are the most common examples of the glandular affections 
in question. I omitted then to notice also, what may as well 
take its place here; since much stress has been laid on it where 
it has occurred, as a wonderful circumstance, though in reality 
but a mere variety deriving from the principle here alluded to. 
This is, that in some cases, the Tic or headach has been attend- 
ed by a transitory, but violent flow of water from the nose; and 
when I have known this amount to a pint in a very short time, 
it is perhaps not surprising that it should have excited wonder. 
If the catarrhal intermittent, for which I have other authority 
than my own, and which is so intimately allied to this variety, 
be admitted here, it will form another example of the same na- 
ture; as the Intermittent Diarrhoea, which I formerly discussed, 
claims also a place in this modification of neuralgic affections. 
I did not formerly notice another case, which, if correctly viewed 
by the reporter, is also an instance of a similar nature; while its 



NEURALGIA OF GLANDS. 303 

truth depends on the report of the patient himself, whose word 
at least I have no reason to doubt, whether his reasoning was 
correct or not The effect in this case was a very troublesome 
increase of secretion from the testicles, accompanying a some- 
what slight, though periodical affection in the vicinity, which 
was clearly referrible to Neuralgia; and attending it also in so 
exact a manner, while his intervals of freedom from the neural- 
gic pain were comparatively those of anaphrodisia, that he at 
least felt no doubt respecting the cause. Nor perhaps was his 
observation unsound; since this last condition should rather have 
existed during the period of ill health, as, in a mere intermit- 
tent, it assuredly would. 

The most pointed case of this nature however that has oc- 
curred to me, is that of the diabetes formerly noticed; and the 
progress of that case was even more remarkable than the com- 
mencement, since it showed a neuralgic affection of the kidney 
existing by itself; a simple disease. It had commenced, as I 
then showed, apparently as an extension of a similar affection 
proceeding along the bladder; but, long after that had ceased, 
the diabetes continued, and as I understand, has not yet, after 
six years, entirely disappeared, returning, however, like the 
chronic fever, at longer intervals. The attacks, during this 
whole period, were, on every occasion, as strictly periodical as 
they had ever been, though the relapses became gradually irre- 
gular in recurrence and duration both, as happens in all the very 
chronic cases of these disorders. Nor, in any instance, did the 
commencement of the saccharine secretion differ from what had 
been the former hour of the attack of the intermittent, or pro- 
ceed beyond its ancient limits; occupying six hours of the day. 
In the interval of the paroxysms, the secretion was perfectly 
natural, as it was in the greater intervals of the relapses; while 
I must further observe, that if the other marks of a paroxysm 
of intermittent were sometimes most conspicuously present, 
amounting indeed often to a troublesome disease in itself, there 
were some relapses in which nothing but the previous expe- 
rience and knowledge of this patient would have traced any in- 
termittent and febrile paroxysm, so slender were the symptoms. 
1 need only remark further on this case, that the pain in the left 
kidney which had formerly attended the disordered secretion, 
occurred afterwards but rarely, yet was always similarly tempo- 
rary, and limited to the paroxysmal period; and that the quanti- 
ty of sugar seemed always proportioned to the severity of the 
paroxysm or of the relapse, being also very remarkable when 
the pain was present, and, on one or two occasions where it 
was extremely severe, being present in greater abundance than 
I ever remember to have seen it in the common diabetes, often 
as that disorder has passed through my hands. 



304 NEURALGIA OF GLANDS- 

As relates to Neuralgia, these occurrences and cases, and the 
last in particular, show that the neuralgic affection, when ex- 
tended to the nerves which supply the glands, can influence their 
secretions; and, as far as we yet see, that this influence is, in 
general, mere increase of action; the last case offering perhaps 
the only exception. Nor is the solution difficult: because, as 
far as we can perceive, a certain degree of the neuralgic disease 
in the minuter ramifications of the nerves, has the effect of in- 
creasing the action of the small arteries, and sometimes to such 
a degree, as will soon be shown, that a permanent inflammation 
is the consequence. 

If this is another new view, it is but a view, however, from 
very limited materials; and it is one, consequently, respecting 
the full value of which we can scarcely conjecture. But if the 
facts are yet limited, that is no reason for rejecting them: and if 
we cannot, without an injudicious exertion of the imagination, 
conjecture how widely they may extend, and what their results 
as to disease may be in other cases, this must not prevent us 
from admitting that future philosophers, with the aid of more 
facts, may be able to draw inferences, the nature of which we 
cannot perhaps foresee. If the neuralgic action on the nerves, 
and subsequently on the vessels of the few glands that have been 
noticed, can produce the effects that we have here seen, and if, 
further, it can produce those very singular inflammations that 
will hereafter be pointed out, we have a pathological power, the 
extent and action of which, as exerted on different parts of the 
compound animal structure, we can imagine to be both various 
and considerable; a possible cause of diseases the nature of which 
is still obscure, and a solution of difficulties, which, if it still 
stops where all pathological investigations do, advances us yet 
a certain step in this difficult inquiry. 

I have but one suggestion more to offer with respect to this 
subject, and it is even a more obscure one than the last. I have 
formerly observed, and shall have to observe again, that the con- 
sequences of severe Neuralgia in any nerve, are very often, ul- 
timately, a loss of power: the result, in those cases where that 
nerve is the servant of a muscle, being palsy, more or less com- 
plete. It is possible at least, therefore, to suppose, that where 
minuter ramifications, not serving muscles, have been affected, 
these also might ultimately undergo, a loss of power, with results 
which can be imagined; as it is useless to dwell on that which 
may not exist. There is an analogy to a certain extent, and 
that analogy may pervade the whole: whether it does so or not, 
is the point to be proved, or otherwise, by facts. But nothing 
will be discovered unless we make such use of these analogies as 
the rules of philosophy justify; while it is by this proceeding 
that science has been, in all its departments^ advanced, if not 



NEURALGIA. OF GLANDS. 305 

created. But if I do not choose'to dwell on this, I will put a 
problematical or imaginary case, that I may show to what this 
kind of reasoning tends. 

If the Neuralgia of the sciatic nerve produces diminution of 
power, or palsy in the muscles supplied by that nerve, a similar 
effect might follow in the nerves of the kidney described in a 
preceding case; and thus the gland formerly secreting in excess, 
might, in the result, become comparatively inactive, or cease to 
secrete at all Or, let us suppose, (what would far better suit 
those who delight in medical hypotheses than myself,) that an 
increased secretion of bile were the produce of a neuralgic de- 
rangement of the secretory nerves of the liver, this might be 
followed by a torpor, or paralytic state of those nerves — and so 
forth; for I will not produce a specimen of that— reasoning it is 
called — which constitutes far too much of the mass of medical 
philosophy. 

I must not close this obscure and unsatisfactory section, with- 
out suggesting how the case of diabetes which I have recorded 
may possibly bear on the practice in that disease. It would be 
very singular if this should be the only instance that ever did or 
ever will occur; and that is surely an hypothesis which we have 
no right to adopt. We have no right to act thus as to any disease; 
and while such a supposition obstructs all progress, it is a truth, 
as I already stated it, that disorders once thought rare and soli- 
tary, become sufficiently common when once they have been 
carefully described and distinguished. There may be many 
such cases; but they will never be found if they are' not believed 
in and understood. Nor is the diabetes that rare disease which 
it has so commonly been supposed; neither is it the inveterate 
and incurable affection, nor always the persistent or chronic one, 
which it has been thought. It has occurred to myself, with no 
great opportunities of observation, very often: and the truth I 
believe to be this, that medical advice is never or seldom asked 
for it, unless when severe or inveterate: whence it has acquired, 
equally, its reputation of rarity and its condemnation as incura- 
ble. In my own experience, it has always been cither cured, 
or suspended for long periods, to relapse and be cured again, 
and without bad results. And further, 1 have had frequent oc- 
casion to observe, that it is sometimes a merely temporary dis- 
order, and also a very slender and contemptible one; while, 
among such cases, I should not be surprised were some found, 
originating in the same cause as the case which I have described. 
This, in fact, I have already suspected in more than one instance 
that has occurred to me: but in no case have I attained such 
command of the case and the patient, as to enable me to say, 
from that evidence without which I have here advanced nothin 
that such was the fact. 



306 NEURALGIA OF GLANDS. 

How far my own experience and suspicions might be support- 
ed by the observations of others, I cannot be certain, as this 
disorder is generally very ill described by authors; but I at 
least find that Sydenham has remarked a diabetes following in- 
termittent fevers of long duration, which, with the laxity not 
unusual in the medical reasoning of all days, he attributes to de- 
bility and a broken constitution. These are not philosophical 
causes for a disease of this nature; but while I may conjecture 
that the cases appertain to the disorder which I have described, 
I cannot prove it, for want of a more accurate description. 

To finish, it will be seen, (if that be held of any moment as 
to the theory of common diabetes,) that this case settles an idly 
enough disputed question, namely, whether the saccharine mat- 
ter is the produce of the stomach or of the kidney. The cause, 
and the fact, here determine the point in such a manner as scarce* 
]y to leave room for controversy, much less for argument. 

But I ought not to conclude this very slender section, with- 
out noticing a case recorded by Strack; an observer of great 
acuteness, whose work, to which I have so often had occasion to 
refer, must, as it seems to me, have been singularly overlooked, 
while I was, myself, unaware of its nature at least, though not 
of its existence, till very recently; since, while he has anticipated 
much which I had imagined my own, on the subject at least of 
anomalous intermittents, though not of Neuralgia, of the nature 
of which he appears to have been utterly unaware, a knowledge 
of what he has written could scarcely have failed to enlighten 
practitioners on the former subject, and thus to have prevented 
a long train of error. 

In this instance, a salivation followed an intermittent fever, 
while it is plain that had mercury been used, a physician thus 
attentive would not have overlooked it. Had there been pain, 
or Tic, also present, it would as certainly have been mentioned ; 
while the cure of the disease by bark, completes the proof of its 
dependence on the fever. He makes no further remark; but 
according to the views which I have here taken, I must consi- 
der it as a transference or localization of the intermittent, or, 
conformably to what I have elsewhere said, a neuralgic condition, 
or action, though without pain, of the salivary nerves. How it 
illustrates the preceding case of diabetes from a similar cause, 
is too obvious to require mention. Such cases of salivation 
ought not however to be very uncommon, since they occurred 
frequently in an epidemic at Leipsic, according to Qualmalz; 
and here therefore at least, there can be no suspicion of their 
having been produced by mercury, as their dependence on the 
fever itself is distinctly stated. 



[ 307 J 



CHAPTER XVI. 



On Neuralgia from Injuries of Nerves. 

This is a subject on which, like the last, I have but a very 
few facts of my own to produce; and yet, few as they are, I 
consider them of some value, not merely in the theory of the 
Neuralgiae, and as they relate to the immediate cause of these 
diseases, but as they illustrate that Neuralgia which has perhaps 
of all been the most grievously mistaken and maltreated; the 
toothach. Hence I have placed this section here; as it will tend 
to throw light on one division of that disease, and on that one, 
in particular, respecting which I have hitherto entirely failed in 
producing conviction, either in the people or in physicians, so 
powerful are prejudice and habit. 

The first case which I shall notice was the most pointed one; 
and being also the first that had occurred to me, its effect was to 
turn my attention to this subject. The patient was a young A 
woman, and the injury was simply the prick of a needle in the 
end of the middle finger; its consequence being a regular peri- 
odical Neuralgia in that finger; which also did not occur till a few 
days after the accident. As some weeks had elapsed before she 
applied for advice, it was easy to ascertain the fact of the peri- 
odical and quotidian regularity; while, at that time, the affection 
of the nerve extended all the way to the shoulder, exactly in the 
same manner as it does in sciatica and in other cases of sponta- 
neous Neuralgia. And as, further, some time elapsed before I 
could effect the cure, I had abundant opportunity of satisfying 
myself respecting the real nature of the disease. That it was 
cured by means of arsenic, will perhaps, to many physicians, 
be an additional proof that I had judged correctly respecting its 
nature. I shall only add, as to this case, what may be a useful 
hint to practitioners in such instances, that the patient herself 
had no suspicion of the regular or paroxysmal nature of the pain 
at the time of her application; and that as it was from my own 
previous views that 1 was led to make the inquiry, so it was not 
-without much cross-examination that I was enabled to get the 
information which I afterwards confirmed by my own observa- 
tion. To expect too much from patients, in point of accuracy 
of observation, is I believe a very common error, and a very 
common cause of erroneous judgments or oversights in physic; 



SOS neurai&ia rsoivi IN JUST. 

while he who knows the necessity of careful cross-examination, 
knows also, as I once before observed, the opposite hazard which 
he may incur from leading questions. 

In the next case, the injury was a blow on the arm, producing 
a severe bruise, a fact however which was only discovered by 
cross-examination, as a regular Neuralgia of a quotidian charac- 
ter was established long before I saw the patient, who was also 
a young woman. In this instance also, I was led to inquire re- 
specting previous injury, from having long suspected that it was 
not a very unfrequent cause of Neuralgia; and the information 
was satisfactory, inasmuch as the disorder was distinctly stated 
to have followed the bruise after two or three days. It was re- 
markable however that the seat of the neuralgic acute pain, 
which was in the middle of the radial nerve, and which extend- 
ed in the usual manner to the shoulder, was not at the place of 
the injury, but considerably distant from it. While under cure, 
this case of Neuralgia lasted long enough to enable me to ascer- 
tain personally its perfectly regular character, and, as in the pre- 
ceding case, that cure was effected by arsenic. 

The third, and the only other case of a very defined character, 
and of which I had a perfect knowledge from the beginning to 
the end, was a case of Neuralgia, quotidian also, in a toe; and it 
had followed immediately after a blow or bruise produced by 
B slipping against a sharp-pointed rock. The surface injured was 
"so small as scarcely to have been perceived at the time; while 
the extreme severity and duration of the pain was a cause of great 
surprise to the patient, as it continued for more than a month be- 
fore it disappeared, and also because it was not in a joint, but in 
the very extremity of the little toe. No remedy was resorted 
to in this case; as the patient, having an opinion of his own, from 
being a medical man, could not be persuaded to view it in the 
light which I did; but it vanished completely and suddenly, leav- 
ing scarcely a recollection behind; though he could not well for- 
get that he had been utterly deprived of the power of walking 
for all that time, as the attack occupied nearly the whole day, 
ceasing only in the evening. With respect to the nature of the 
disease, this natural cure is as satisfactory as the cure by arsenic, 
since it happens perpetually in Neuralgia: and with regard to 
this patient, I may add that he had at different times been affect- 
ed by that disorder in the face, and had also suffered from chro- 
nic intermittent; a state of things under which all the Neuralgia 
of remote nerves are most apt. to occur. 

Another case of what I considered the same disease, and from 
a similar cause, did not come under my notice till many years 
after it had been established, and when the recurrences had be- 
come as irregular as they always are in Neuralgias of long stand- 
ing. So distant indeed was the time, that the patient, never 



NEURALGIA FROM INJURY. 309 

having had his attention called to that point before, could only 
recollect generally, that he had, for a year or two after the inju- 
ry, been subject to violent pain, which was sometimes described 
as constant, and sometimes as daily, with all the usual hesitation 
that attends such distant recollections: though I could extract, by 
one circumstance, that it was probably a quotidian and tempora- 
ry pain, because he could not assert that he had ever observed.it 
but during a certain portion of the day, when he was occupied 
in his counting-house writing; a fact which served to fix it in his 
memory. When this case first came under my examination, 
the pain was clearly temporary and quotidian, occurring in dis- 
tinct relapses for a certain number of days or weeks, and then 
disappearing: and, fifteen years afterwards, I found that it was 
so far diminished in frequency, that it occurred, then, no other- 
wise than from particular changes in the weather, actual or im- 
pending. That he thus considered, himself as a perfect baro- 
meter, or capable of prognosticating atmospheric changes of 
consequence, often twelve hours before their occurrence, is a 
fact which, however inexplicable it may be, or however ridi- 
culed, is unquestionably as established, as, in the case of corns, 
it is vulgarly proverbial; since it occurs familiarly with respect 
to amputated limbs and similar injuries, and happens also in 
many Neuralgias of old standing. 

In this case, as I saw it, the pain was distinctly that of a 
Neuralgia; its seat being the injured part, which was a finger in 
which a fragment of glass had been buried so as to leave a small 
induration; the usual pain extending upwards to the shoulder, 
with increase of heat and sensibility in the hand, and particu- 
larly about the injured part, during the paroxysm, which was 
always perfectly definite in duration, though not regular in re- 
currence, during the many years that I had opportunities of re- 
newing my inquiries. This patient would not use any remedies, 
having been, originally, long tormented in vain with local ap- 
plications: nor did I press what, in cases of such long standing, 
I have most generally found useless. But I must add, as a bet- 
ter reason, that he offered an example, also, like the preceding 
patient, of that aversion to admit of this view which I have 
found so general, I will not say universal; of that incapacity for 
conviction which is most incorrigible in those who, from their 
education, as it is called, or place in life, imagine that they must 
. be possessed of what is termed reason; a faculty which, with 
its application, called reasoning, philosophy presumes to be the 
.only true and just foundation lor opinions, and on which, never- 
theless, not one ia ten millions of the opinions existing or formed 
in society have ever been or ever are founded. 

If this case is less defined and satisfactory than the former 
ones, it is still, if wc omit the injury, exactly the description of 



310 NEURALGIA FROM INJURY. 

a real and spontaneous Neuralgia as this is most generally met 
with in practice; at least by such physicians as are commonly 
resorted to when former ones have failed: nor do I hesitate in 
considering it as a case of this disorder arising from the injury 
of a nerve. And it is because of its being an obscure case, that 
I have chosen to be thus minute in detailing it: since it is to 
mislead readers or students, to cause them to expect in practice 
that every case of disease shall be a definite and obvious one; 
as it is to prevent them from acquiring that discernment in ob- 
scure and imperfect ones, which, in nine cases of ten through- 
out the whole Nosology, is that of which they will most stand 
in need. 

If I have no more cases of this nature, of any particular va- 
lue, to add, I know not that any thing would have been gained 
hy such addition. The evidence is perfect; and I have little 
doubt that the fact is much more common than it has yet ap- 
peared to be, and that, while all the painful affections of the 
nerves from injuries must be referred to this disorder, so it will 
be found, now that it is distinctly pointed out, that they are re- 
gular or intermittent in as great a proportion as other Neural- 
gia, and that they will probably be cured also in the same pro- 
portion, and by the same remedies. 

It is thus proved that the mechanical injury of a nerve will 
produce, not merely the permanent pain which it is known to 
do, but a Neuralgia as regular as that which arises from Malaria 
and is connected with intermittent fever, or from those other, 
unknown causes, under which it occurs as a spontaneous disor- 
der, or a disorder without assignable injury. And, in practice, 
it is a fact of considerable value; since these cases have been too 
often considered as incurable, or at least not within the reach 
of medicines; as the two which I first described had been pro- 
nounced by the practitioners from whom I received them. But 
for the remedy employed, these would probably have become as 
inveterate as that which I described last; continuing perhaps for 
life, as is too common with all the Neuralgias when suffered to 
establish themselves. 

And though I have had no opportunities of putting this into 
practice, such is the analogy here, that I should expect to find 
that the remedies of Neuralgia, bark and arsenic for example, 
or whatever else it be which succeeds in this disorder, would 
be found effectual in the pains of the nerves that follow injuries, 
even if they were not periodical and regular: thus providing us 
with the means of remedying a species of distress which I ima- 
gine must be very familiar to surgeons, and far more common 
than a physician, rarely consulted in such cases, can even con- 
jecture. If in my own former, military, practice, they have 
not appeared so to occur, surgeons themselves can easily explain 



NEURALGIA FROM INJURY. 211 

I 

this: knowing well the different attention which disorders con- 
sisting of mere pain or inconvenience experience, in private 
practice, and in the army. 

And before I terminate this brief section, I must not forget 
to remark, that I have known sciatica itself produced by a blow f 
on the parts which cover that nerve, in more cases than one; 
confirming the present views: while I have no doubt that it has 
occurred to many other physicians. Thus have I seen an analo- 
gous disease, in several instances, produced by a blow on the 
sacrum ; a painful disorder which could not be called lumbago, 
permanent long after the original injury had disappeared, and 
similarly extending its influence along the remoter nerves; while^ 
in one case, the consequence was, simply, an affection within 
the rectum, lasting for many weeks, and described by the pa- 
tient as resembling tenesmus; a disorder which I have little 
doubt was a Neuralgia of that part, analogous to the spontane- 
ous case which was formerly described. But it is sufficient to 
have named some of these more marked cases; as I need not 
encumber this evidence with further details of the same na- 
ture. 

I was not aware when I made these observations and drew 
these conclusions as to the painful disorders following injured 
nerves, that any other physicians had supposed them to apper- 
tain to Neuralgia; they having occurred twenty years ago, when 
I was without access to books, and the subject having, till again 
very recently, ceased to engage my attention. But on reading 
now for the purpose of discovering authorities in support of my 
own opinions, I find a considerable number of instances where, 
a similar view I should say, rather than the same one, has been • 
taken; though as in all other cases of this disorder, no generali- 
zation has been made, nor any consistent and rational mode of 
practice adopted; the usual mysterious view under which Neu- 
ralgia has been considered, having been applied to these cases, 
even when thus explained, which is far also from being always 
the fact, and the remedies having, in a similar manner, been 
empirical and tentative. 

If I can therefore bring no proof from the practice of others, 
that the remedies of intermittent are those of this variety of 
Neuralgia, as of all others, a notice of some of these cases will 
still be of value, as proving that this is a very common form of 
that disorder, or that Neuralgia is the frequent result of injuries, 
while it will also indicate to practitioners, the necessity of pay- 
ing a different kind of attention to them from what they have 
yet done. It is unpleasing to feel that this cannot be done with- 
out criticising the opinions and the practice of able and atten- 
tive men, and sometimes, of personal friends; but such feelings 



312 NEURALGIA FROM INJURY. 

must not be put into competition with the higher duties which 
every physician owes to society. 

In a case noticed by Sauvages, the disorder was the result of 
a blow, and was seated in the head and neck; this case corres- 
ponding in its cause to that which I have described as occurring 
in an arm. In one under the management of Wardrop, the 
cause was a prick in the thumb from a thorn: and while the dis- 
ease was a plain case of Neuralgia, I can only perceive that it 
was called an injury of the nerve. The absence of the appro- 
priate term would, it is evident, render this case of little value 
to those who are governed by terms, even had an efficient and 
correct practice been adopted. 

A more remarkable case is one recorded by Swan, where the 
Neuralgia followed a cut in the thumb, and lasted seven years. 
He also calls it an injury of a nerve: and while he does not even 
rank it with Tic or Neuralgia, his remark is, that no remedies 
were of any use. That is to say, the remedies which he adopted 
were of no use, because they were not the proper ones; though 
the mere duration of this case should have caused a suspicion of 
its nature, in any one who had ever thought on the subject of 
Neuralgia. If I am sorry to make such a remark, I may also 
add my suspicion that the place of this patient and physician, 
Lincoln, will assist in explaining the duration of this case; and 
it is not improbable that the endemic of the country was united 
to, or aiding in it. Two other cases related by the same au- 
thor, one arising from a blow on the eye, and another from a si- 
milar injury on the face, are of no other value than as further 
showing that this singular disorder can be produced by local 
causes; though 1 cannot help entertaining a suspicion that not 
only in these Lincolnshire cases, but in all others, Neuralgia 
from injury is most likely to attack those who have a tendency 
to intermittent fever, or have formerly been subjected to it, or 
are exposed to its ordinary causes. This conjecture is founded 
on the facility with which Neuralgia happens from partial ex- 
posure to cold, as also from causes less obvious, in those who 
are thus situated: nor is it difficult to conceive further, how the 
habit of periods, to use this phrase, should interfere in the case 
of a direct injury to a nerve, and thus regulate the form of the 
disease so induced. 

If I described a case where Neuralgia of the arm was pro- 
duced by the prick of a needle in the ringer, I might then also 
have mentioned the cases which have occurred in my own prac- 
tice, as I doubt not in that of every practitioner, of painful dis- 
orders following blood-letting, and apparently from injury of a 
nerve. But as in none of these the pain had assumed the peri- 
odical form, I was unwilling to prejudge the question, or decide 



NEURALGIA FROM INJURY. 313 

without precise evidence; while I am gratified in finding record- 
ed cases where this was the fact. These are noticed by many 
authors: but I shall refer only to Sabatier for one, because it 
lasted six years, and because, in that case, the division of the 
nerve was recommended, as it has so generally been in ordinary 
Neuralgia. The long continuance of this case proves, what in- 
deed the history also does, that it was not understood; and simi- J 
larly, in all the rest, I can find no definite views of the nature 
of the disorder, nor even a suggestion that it belongs to common 
Neuralgia, far less to an intermittent type of disease, or that the 
cure should be attempted by the same remedies. If the actual 
practice of Swan and some others, in this as in other cases of 
Neuralgia, has sometimes been good, it has been by chance, and 
in the course of a rotation of random experiments; while his 
recommendation in all cases, as far as I can make out, is the di- 
vision of the nerve, as usual. 

Cases from tumours pressing on a nerve have not occurred to 
myself; but I gladly trace them in authors, because they add to 
the catalogue of the injuries which are capable of producing this 
disorder. Thus Swan describes a case of this nature from a po- j 
pliteal aneurism, the pain being in the leg, and in a regular quo- 
tidian form. It was cured by or after the operation; while we 
may express our surprise, that to a physician who had bestowed 
so much attention on diseases of the nerves, and to these cases 
among others, and to whom intermittent must have been equally 
familiar, the periodical nature of this one did not suggest the 
true theory, or at least the true remedies. In another analogous 
case, the tumour which caused the disease was produced by a 
blow on the thigh. 

The last class of injuries producing this effect which has not 
occurred to myself, but which I also find recorded, consists in 
ulcers: in ulcerations of such character or permanence as to have 
corroded, or destroyed, or perhaps merely laid bare a branch of i 
a nerve. They require no particular criticism; but they have a 
value in the views which I have here given, because they illus- 
trate the case of toothach from a carious tooth, since that is an 
ulcer similarly affecting a nerve; while it may be thought that 
whoever had supposed such an affection from an ordinary ulcer 
to be true Neuralgia, ought to have formed the same universal 
conclusion as to toothach. That this has never yet been done, 
assists in proving what I have so often here advanced; that, using 
this term in its philosophical sense, the procedures of physic, 
have been empirical, from its origin to the present day, that it 
has never conducted itself by the laws of science, and that while 
iseeming unaware of the powers and utility, as of the necessit}-, 
of generalization, it has not even proceeded in a correct manner 
in the investigation of its facts: thus, if ignorant of the method 

40 



314 NEURALGIA FROM INJURS*. 

of erecting a superstructure, neglecting even the means of lay- 
ing a true foundation. 

If I have remarked the singular effect which changes in the 
state of the atmosphere produce on nerves affected by Neuralgia 
from whatever causes, and very strikingly in the case of injury? 
it is at least interesting to remark that this bears a close analogy 
to the fact just alluded to; namely, the effects of the same na- 
ture, produced from the same cause, in amputated limbs or other 
ancient and severe wounds; as also in that case, somewhat mean, 
it must be admitted, already quoted, namely, corns. In the 
former class of cases, nerves have been injured; and, in the last, 
we must conceive a persistent injury, pressure, analogous to that 
described in some of the foregoing ones. The conclusion would 
not be much overstrained, were we to suppose, that, in such in- 
stances, the nerves are in a state at the injured part, similar to 
their condition in common chronic Neuralgia when dormant, 
(an unknown one we must regret,) and ready to be excited to 
pain by the application of an occasional cause. Hereafter, pos- 
sibly, these considerations and analogies may aid in throwing 
light on the immediate, or proximate cause of this class of dis- 
orders; though I cannot pretend to say that such uncertain Neu- 
ralgic pains would, in any case, be remedied by the means which 
are successful in the more regular and marked diseases of this 
nature. 

But before I part from this branch of the subject, I must re- 
mark that Swan and other authors besides myself, have recent- 
ly begun to consider the pains which are produced in wounds 
during their healing, whether from ligatures on the nerves, or 
ulcerations, or the general injury, as analogous to Neuralgia; a 
fact, of which I never entertained a doubt. How far these may 
be amenable to the treatment of common Neuralgia, is a trial 
which I must leave to others, and to surgeons; since I can have, 
now, no opportunities of putting it in practice. That this has 
not been yet attempted, as far as I can discover, is only a natu- 
ral consequence of what I have so often noticed; but the cure of 
the toothach from caries, in this manner, holds out at least the 
promise of being able to relieve, in this way, no small mass of 
distress. And this also suggests a very difficult and delicate 
question, approaching too nearly to a hypothetical speculation ta 
be hazarded without some repugnance. It relates to tetanus as 
the result of similar injuries. That this is one of the most ob- 
scure diseases in physic, as it is among the most formidable, is a 
truth too well known; yet there is some analogy, if not very 
f near, between Neuralgia producing convulsions or spasms, and 
™ this disorder; while, in some cases, it is preceded or accompa- 
nied by pains in the nerve which has received the injury. But 
I will not pursue what is but a hint towards further inquiries: 



TOOTHACH. 315 

only, if it shall prove that there is even an affinity of a remote 
nature between the two, it may not ultimately prove useless in 
regulating that practice as to tetanus which is now so vacillating 
and so undetermined. 

Lastly, if I have noticed the subject of corns, it will not be 
useless to repeat somewhat more distinctly, that even the ordi- I 
nary pain from this cause, well known to be often very severe, 
far more so indeed than can well be explained on any other 
view, and not less well known to be sometimes periodical, may 
be, or rather probably is, a Neuralgia from injury: and it will 
be deserving of trial whether such pains may not be removed 
or abated by the remedies of that disease, in any case often suf- 
ficiently severe to justify a proceeding of this nature. Under 
any view, the analogy is too remarkable to have permitted me 
to pass over what, if a trifling fact in itself, is not such as it re- 
lates to medical philosophy. 

Before I conclude this chapter I may add a remark, or rather I 
a conjecture, to be verified, or not, like many more, by future 
observation. It relates to the chronic, and often very remarka- 
ble pains, which follow injuries, such as sprains and bruises, and 
which are generally referred to rheumatism by physicians, 
though often vaguely attributed to the original injury, by those 
who never think of inquiring how that can ant at such a dis- 
tance of time. On some occasions, I have had abundant reason 
to believe that these belonged to the class of Neuralgise from in- 
jury: and were they even called rheumatism, it may be ques- 
tioned whether that rheumatism is not of the same character; 
while I need not dwell on what was formerly suggested as to 
rheumatism in all its forms, when I took occasion, in the first 
volume, to point out its remarkable connexion with intermittent 
-fever. 



CHAPTER XVII. 



On Toothaclu 



If the subject of the present chapter may seem to occupy 
more space and to be treated with much more detail, than so 
vulgar and apparently so well known a disorder can justify , the 
more particularly when it has occupied numerous treatises and 
is conceived to be as thoroughly understood as any thing in phy- 



316 TOOTHACE. 

sic can be, the necessity for such detail will soon be apparent-* 
since not only is it closely connected with most of the leading 
facts belonging to Neuralgia, but it is only by drawing those 
analogies, somewhat minutely, that I can expect to establish the 
present views. And since utility, the wish to diminish human 
misery, is the object of this entire essay, it is not by the inten- 
sity, the mortal power, or the popularly terrific character of any 
particular disease that its value must be measured, or that I have 
myself measured it, but by the arithmetical quantity of suffer- 
ing which it produces. The hydrophobia may be an object of 
interest or of universal alarm: but he who shall discover a sure 
and rapid remedy for even a common catarrh, would be a greater 
benefactor to his race than the man who may invent a specific 
for that celebrated disease. 

But whatever arguments or evidences I may produce for the, 
purpose of proving that toothach, in all its modes, is a Neural- 
gia and nothing more, a variety of the general disease under 
consideration, however perfectly I may draw the analogies, and 
thus unite every variety of this disorder under one leading form, 
while I also connect them with the simple Neuralgia of the same 
part of the body, I enter upon the subject without the slightest 
hope of producing the conviction which I feel, which I have 
felt almost from the first moment that I had entered on the stu- 
dy of physic. 

It is not that I expect opposition from arguments, nor from 
medical facts or principles, assuredly at least, as 1 hope, not from, 
enlightened and philosophical physicians: the difficulty arises 
chiefly from moral impediments; and they are such as were ne- 
ver yet surmounted without the aid of patience and time, being 
the obstacles which have invariably encountered every novel 
proposition which has tended to overturn a popular and esta- 
blished error or system. It is scarcely in man to admit that a 
belief which has lasted almost since the beginning of the world 
is not well founded; that what appears as plain as it is univer- 
sally received, is not true, that mankind has so long proceeded 
under error and ignorance, and that a majority comprising eve- 
ry individual in the world from the creation, except one person, 
is in the wrong; far less to concede that this visible, every-day 
individual, one of the general mass, is the person capable of 
overturning the universal belief, and of establishing his own 
opinions or belief in its place. This is human nature; and it is 
the history of all attempts of this kind in the " quidquid agunt 
homines;' 7 in every thing at least that is of familiar or universal 
reception. 

Nor do I consider, that, against such a feeling, the most in- 
controvertible proofs would produce conviction; because I be- 
lieve that in reality there is no such thing as conviction, except 



TOOTHACH, 317 

m» *< 

ift the solitary case of mathematical demonstration: where^the 
facility of convincing arises, in a general sense, and with excep- 
tions which it is superfluous to notice, from two causes chiefly^ 
rather than from the purity of proof and the exertion of rea- 
soning powers; and each of these being moral causes, while the 
first is that which, as the foundation of all opinion, is the very dif- 
ficulty against which we have always to contend in other cases. 
The one of these is, a universal prejudice or rooted opinion, 
that mathematical science can prove what it undertakes; and 
the other cause is, that men are perfectly indifferent what it 
does prove, and would be just as well content were it demon- 
strated that a triangle comprised ten right angles as two. In 
every other case, there is habit, passion, prejudice, interest, what 
not, on the one side, and demonstration, which, to the multi- 
tude, is nothing at all, on the other; since to none is that a ground 
of — belief; as I will not abuse the term conviction by thus ap- 
plying it. 

If there is any one disorder on earth, at least in civilized so- 
ciety, which is universal, it is the toothach; since few, indeed^ 
have passed through life without experiencing it. And while 
its frequency and familiarity have rendered the entire mass of 
mankind, almost every individual that ever existed, judges and 
physicians on this subject, at least in their own estimation, so 
have that and other circumstances taken its treatment, as well as 
its theory, almost out of the hands of physic, to lodge it in the 
hands of those who, on a point of this nature, can scarcely be 
the best of philosophers. 

But among all, among physicians and the multitude alike, the 
leading cause of the error on this subject, is somewhat similar 
to what I had occasion to point out before. There is, in the 
first place, a term, a name as old as physic; and I need not again 
say that a successful and popular term is, in itself, philosophy; 
cause, theory, every thing; or that it stands at least in lieu of 
all reasoning and all investigation. It is the Toothach; that is 
sufficient: after the philosophy is established, the remedies fol- 
low of course, and, in this case, it is extraction, the amputation 
of the imagined seat of the disease: the remedy of the Dracos 
in legislation for the extirpation of moral diseases. 

As an aid to this reasoning, the very ground- work perhaps of 
the whole, toothach is pain, pain in a tooth; and thus the entire 
definition, the whole philosophy and theory, are comprised in 
this sole feature and term. But when this pain is present, the 
tooth is frequently unsound, diseased, and carious: and thus is 
the opinion that the pain proceeds from the visible disease, more 
firmly fixed, while this leading variety becomes the type and 
parent of the whole. Thus, if the tooth is not really carious, 



318 TOOTHACH. 

it will be so hereafter, or it ought to be so; or it is diseased in 
some other manner (ingenious men find out that there is an ab- 
scess concealed,) or, as even Cullen has determined, "it is al- 
ways dependent on some immediate application of acrid matter 
to the nerves of the teeth," or, in short, (for who shall find rea- 
sons for those who have none?) it is a diseased tooth in some 
way, because it gives pain, and therefore it must be extracted: 
while, at this conclusion does Cullen himself arrive. And if, 
after all, the disease is not even in the tooth, but in the jaw, 
then it must be in the roots, or in the antrum snaxillare, or some- 
where else; and still it is "the toothach," and still the tooth, or 
all the teeth, as it may happen, must be extracted. 

Very seriously, such is the theory of toothach, in the hands 
of many more than Cullen: and such the leading practice at 
least; the ultimate remedy. And I believe it further to be true, 
that if physic and physicians may appear here to be blamed, and 
also to deserve blame, there are some excuses to lighten their 
share of the demerit, as to the practice at least; though as far 
as they have taught what should be concluded and done, they 
have had ample liberty. If the toothach ever falls within their 
department, it is, more correctly, the business of surgery, un- 
der the views of the fundamental remedy which are entertained; 
but it is the patient most commonly who is the real physician, 
and who dictates what is to be done; while the remedy is ad- 
ministered by the druggist, or, if it be extraction, by the apo- 
thecary's apprentice, to whom it is the virgin operation of his 
surgical education. When the barber is the physician in these 
cases, the philosophy and the practice are not better, and could 
not be much worse. 

And still there is another cause, and that cause is the one 
which has promoted the barber to the rank of dentist. It is not 
here my business to inquire into the utility, or rather the inuti- 
lity, of a dentist and his operations: nor to encounter, unneces- 
sarily, the prejudices respecting the wonderful value of his va- 
rious arts, which are entwined with the most invincible feelings 
of our vain nature. Yet I may question whether he who is an 
ingenious workman in ivory, he who is a vendor of secret pow- 
ders and washes, he whose strength of hand is not checked by 
any superfluous refinement of feeling, or he who knows no more 
of the human anatomy than that some teeth have one root and 
some three, is exactly the fit person to reason about the diseases 
of the human constitution or to be intrusted with their cure; 
and, most of all, where, to blind habit and mechanical practice, 
there is occasionally added a small bias of self-interest. If this 
doubt be well founded, let the dentist who is a surgeon, or the 
surgeon who is a dentist, (for such, fortunately, there also are,) 



PERIODICAL TOOTH AC H. 31J> 

be the person to be intrusted, at least with the toothach: since 
should he not know its nature at present, it is he at least who 
will learn to understand it. 

But I must pass from these general remarks, which were really 
necessary for the purpose of anticipating the objections which I 
foresee; while if they are taxed with severity, the apology is 
ready. It is the cause of human nature, of all mankind, against 
that of a few individuals of that great mass; and the smaller evil 
is counterbalanced by the general utility. 

I shall now proceed to describe this disorder as far as is ne- 
cessary; but it is here especially requisite to distinguish it into 
varieties; as on a due division of those, much of the arguments 
which I have to produce respecting its real nature depend. And,, 
on account of those views, I must be permitted to form my own 
division, and hence to neglect whatever has been formerly writ- 
ten on this subject. Yet as I shall not attempt to give so full 
an account of toothach under all its forms and connexions as if 
I were writing a sole treatise on that subject, I shall still sup- 
pose that the reader has studied, or will study, many works 
where he will find useful information, if generally under a false 
theory. My object here is, to reduce the disease under such 
leading forms, that the cases which occur may be referred to the 
one or to the other; to establish an analogy throughout those, 
first, and further, between the whole and Neuralgia, by evidence 
and reasoning; and, finally, to which all this tends, to point out 
what appears to be the rational method of cure. For this pur- 
pose, extreme minuteness and detail are not required; because 
if the leading objects are attained, the outline can always be 
filled up by every physician; and the plan followed here is there- 
fore that which has been adopted throughout the whole of this 
essay. 

The heads under which toothach is divided, may, for the pre- 
sent purpose, be conveniently rather than correctly, assumed as 
the following: but they are very indefinite divisions, as they run 
into each other, and, as individual cases, present endless modi- 
fications. 

It may be rigidly periodical: while, in this case, it may be 
either combined, or not, with chronic intermittent fever: and 
further, in this case also, a tooth, or teeth may be sound, or ca- 
rious, this condition being here considered incidental, not essen- 
tial. Or, it may be irregular in its paroxysms, under all the 
same variations; and in both of these varieties, it passes into the 
common Neuralgia of the face, or, cases occur in which either 
name is equally applicable. This is the periodical toothach so 
familiar to those who have paid the attention to this subject 
which it deserves, but which is so very often overlooked, not 
merely by the physician, but very generally, ifjsomcwhat move, 



320 PERIODICAL TOOTHACH. 

remarkably, by the patient; as, by the former, its passage into 
highly marked Neuralgia seems equally to have been neglected? 
and most so when a carious tooth is present. 

In these forms, it is here considered as spontaneous Neural- 
gia: while, in the next place, it may occur, either casually, or 
more regularly, that is, under all the variations of that general 
disease, and traceable in a marked manner to a carious tooth; 
the pain being fixed in the nervous branch by which that is sup- 
plied, or originating in that and spreading from it. In this 
form it is here referred to Neuralgia arising from an injury to a 
nerve. 

Further, as happens in cases of common Neuralgia, the ex- 
citement of the minuter vessels may be such as to produce tem- 
porary and paroxysmal, or, more permanent inflammation in the 
^ membranes, or generally about the face; when it becomes rheu- 
matic toothach or rheumatism of the face, (neuralgic inflamma- 
j tion.) The chief varieties here, are produced in the following 
manner. The general (rheumatic) inflammation may, as I have 
just suggested, be paroxysmal and periodical, and even regular, 
or it may be permanent; while it may attend a carious tooth 
which is pained, or free of pain, or else a sound tooth in a state 
of pain; and such pains under any mode of regularity or other- 
wise. It may also be accompanied by a neuralgic pain inde- 
pendent of the general pain of the inflammation, and not in a 
tooth; in which case, it is plain, it belongs most unquestionably 
to Neuralgia, though, in the usual practice, ranked with tooth- 
ach. 

Or, lastly, all other pain but that of the inflammation itself 
may be wanting; when it becomes, most strictly, what is called 
rheumatism of the face: this state also sometimes occurring, 
even without the presence of a carious tooth. If this rheuma- 
tism of the face with separate neuralgic pain should in correct- 
ness have been ranked under common " Tic," the last division, 
also, in a more scientific arrangement, should have been reserved 
for a distinct section: but its obvious affinities and the received 
usage render it convenient to include it in the present one; par- 
ticularly as its limits with respect to the former varieties are in- 
definite. 

That I have justly referred all these diseases or varieties of 
disease to Neuralgia, will I think appear in the course of the 
description: and consequently, that I am justified in consider- 
ing toothach, universally, as this disorder, or as a species in the 
leading genus treated in this essay. I shall therefore proceed to 
describe them as far as is necessary; while I shall in conclusion 
attempt to sum up the evidences in a condensed form. 

The rigidly periodical toothach is by no means an uncommon 
form of the disease, but it must be sought to be found; its regu- 



PEltrODlC'AL TOOTHACHo 321 

larity being almost always overlooked, as I have just observed, 
as well by the patients as by practitioners. In scarcely any one 
instance out of hundreds that have occurred to me, has this cha- 
racter been observed by the patients till it was suggested; and 
in many, it has required some argument, added to many days of 
compulsory self-examination, before the fact was admitted. So 
strong are prejudices in this case, and especially where there 
chances to be a carious tooth; so long has it been the habit to 
consider the pain as produced by this cause, and the disorder as 
a purely local and independent one: while I may also add, that 
the suspicion entertained respecting a favourite system on the 
part of the physician, often increases the opposition to this view, 
from very obvious and common moral causes. And further, if 
it is npt more frequently observed, the cause lies also in a great 
measure with the practitioners. Even where these are me- 
dical persons, the vulgar conviction that this is a purely local 
disorder, or the ignorance that it possesses the connexions 
which I am endeavouring to prove, added to a species of ne- 
glect, or a contempt for an ailment which is almost proverbially 
despised in another person, is productive of carelessness, and 
causes every circumstance but the pain itself to be overlooked; 
thus perpetuating that ignorance which it is my object to remove. 
But as, even where physic is resorted to, medical persons are 
much less consulted than dentists, to whose whole philosophy 
r on this subject I have already alluded, it is much less surprising 
that so little discrimination is exerted respecting this disorder; 
while it must further be remembered, that as far as the charac- 
ters of a disease are to be assigned from general averages or 
arithmetical numbers, from the multiplicity of cases studied, 
this is one for which the far greater portion of the people de- 
mand no advice from any one, unless perchance from the apo- 
thecary's apprentice or the nearest barber. 

Any person who chooses to seek for them, will find cases 
where the periodical return and the paroxysmal duration of 
toothach are as regular as those of the most regular Neuralgia or 
Intermittent fever, and under every variation under which these 
occur. And this is equally true whether there is a carious tooth 
or not; while, where that is not present, these cases by occupy- 
ing a particular spot or region, and by the quality of the pain, 
pass gradually into the common and regular Neuralgia of the 
face (Tic) by gradations so insensible as to have no defined 
boundary. And while those who may think fit to pursue this 
inquiry, and prove the truth of what is here advanced, must 
conduct their investigations upon this principle, they must not 
forget that such paroxysms occur very frequently in the night, 
or at least, on a calculation of chances, as often, of course, as in 
the day; and that it is in such cases in particular, that it is t! 

41 



322 PERIODICAL TOOTHACH. 

cult to extract the truth from a patient: while there is not one 
in a thousand who can be persuaded that such a disease is con- 
stitutional as well as local, still less, where there is a carious 
tooth, that the pain can be removed by bark or arsenic, or by 
internal remedies of any kind. 

Whether it is really true that periodical toothach occurs more 
frequently in the night than in the day, I cannot decide; but so 
assuredly it has appeared to do in my own experience. If true, 
it may be thought remarkable, as the paroxysms of intermittent 
fever are most frequent in the daytime: yet it is not perhaps in- 
explicable, as it is obviously a disorder easily influenced by oc- 
cupation or impressions on the mind, while it must be recollect- 
ed also that every pain appears to a patient most intense in the 
solitude and silence of the night. Thence the unhappy fate of 
physicians, perpetually summoned from their beds by the self- 
ish, during the idle alarms of a night watching or nocturnal 
awakening: alarms which the return of daylight would have re- 
moved, which even a candle and a book might have dissipated. 
In transient, or acute cases of periodical toothach, it is less 
easy to perceive that there is any general affection of the sys- 
tem; though a discriminating observer will often find the usual 
symptoms of obscure intermittent fever, even here. When 
chronic, or habitual, it is more easy to observe this, as far as my 
experience goes. In any case, the symptoms are those which I 
formerly described as attending Neuralgia, and need not repeat; 
while the painful state is also the hot stage of the paroxysm, or 
at least is most severe at that time. And if the local action is 
here considerable, the excitement of the minute vessels often 
produces a swelling, or rheumatic pain, or tenderness, of the 
surrounding parts, which is equally paroxysmal and transient. 

In such cases, and indeed in almost all instances of long con- 
tinued or habitual toothach, even if irregular, an acute observer 
will easily perceive that peculiar physiognomy which I have so 
often described; and few physicians can be familiar with such 
cases of toothach, without having noticed the singular complex- 
ion often present; transitory at times, but often as fixed as are 
the visceral diseases so often present in those who are subject to 
chronic and inveterate toothach. This is a fact which I must, 
however, notice again, and shall therefore pass over at present. 
But further, this regular toothach is very often found in per- 
sons who are labouring under chronic intermittent; forming 
sometimes a kind of appendage to that disorder, at others, re- 
placing a paroxysm or a series of paroxysms. Thus have I 
seen a case of what must be considered a double tertian, an ague 
formed in China, of a variety notorious for its inveteracy, where 
one of the alternate days presented a regular and simple inter- 
mittent paroxysm of considerable severity, and the other a tooth- 



PEliXODICAL TOOTH ACH. 333 

ach equally regular and severe; the disorder having lasted under 
this form for nearly a twelvemonth when it came under my no- 
tice. Other cases, of a similar nature, but less durable and de- 
cided, have also occurred to me; as have more instances than 
one of a double quotidian with similar alternations. Thus also, 
in such chronic intermittent, have I seen an entire relapse, con- 
sisting of toothach, and alternating, no less than three several 
times, with relapses of simple intermittent; while, in others, a 
severe period of toothach, occupying some weeks, has suddenly 
ceased on the occurrence of a series of simple intermittent pa- 
roxysms. And in these cases, let me remark, the same exact 
period was preserved in both disorders; the toothach, when its 
relapse was in existence, occurring at the same hour as the fe- 
ver had done in the other ones. 

In an analogous manner, this toothach is found in patients of 
this description, replacing other neuralgic afiections; and thus 
have I found it to alternate in these several ways; that is, ei- 
ther by paroxysms or relapses, with hemicrania and clavus, or 
other varieties of periodical headach, with periodical rheuma- 
tism in a shoulder, with Neuralgia in the fingers, and with that 
palpitation of the heart which I consider as a Neuralgia; nor do 
I doubt that greater experience in a disease which is seldom ac- 
cessible to physicians, would have given me a far greater com- 
mand of minute and particular evidences of the same nature. 

One, however, I may still notice, for its remarkable combina- 
tion, while the leading type must be referred to the double quo- 
tidian; and it is important to remark that, in this case, the pa- 
tient had been long subject to double quotidian under many dif- 
ferent modes. In this instance, the toothach alternated daily 
with a headach; while, on both days, after the cessation of the 
pain, there occurred a regular intermittent paroxysm, being pro- 
bably the second quotidian fit and not a continuation of the pain- 
ful one. In this particular patient, under every form of the dis- 
order which he had experienced, there was seldom more than tin 
hour or half an hour of interval between the cessation of the 
first and the occurrence of the second paroxysm. 

If I have thus described a regular periodical toothach, I am 
perfectly aware that such a disorder has been long known to 
physicians; but if I am describing an acknowledged disease, I 
trust that I am also correcting the history of one that has been 
misapprehended, since, while it has generally been treated of as 
a mere casual variety deserving of no particular notice, while 
commonly also overlooked, or confounded with ordinary tooth- 
ach, I can find no work in which its dependence on intermittent 
has been pointed out, still less where it has been referred to 
Neuralgia, or even connected with the periodical headach to 
which it is so nearly allied. It is, however, evident that it is 



324 PERIODICAL TOOTHACH. 

the most important variety of this disorder; since it forms a 
main connecting link between all toothach and the generic dis- 
orders to which that is affiliated, as it constitutes also, almost the 
basis of the whole investigation. 

It was here therefore a fundamental necessity, as it was my 
main object, to point out that connexion which it possesses with 
intermittent fever and with Neuralgia both, which has never yet 
been fairly understood or admitted; to show, in fact, that this 
toothach, be its varieties what they may, is a mode of intermit- 
tent fever with local symptoms, or a neuralgic intermittent, and 
that it forms but a variety in this general division of the leading 
disorder. Should the febrile symptoms, or the accompanying 
intermittent, be not present, or difficult to discern, it will still 
be a regular Neuralgia at least, to those who continue unwilling 
to admit the connexion between these two forms of disease. If 
this view is important as it relates to the cure of periodical tooth- 
ach, so is it with respect to the remedies of that painful disorder 
under any form; but it is of even more importance in enabling 
us to establish a just theory of the entire disease; in attempting 
to prove, as I hope to do, that every toothach is a Neuralgia, be 
its forms whatever they may. 

This is a truth which, when once presented, will strike every 
patient at least who has experienced common Neuralgia of the 
face (Tic) and toothach, whether it should convince him or not 
as to the general truth of the present theory; so exactly similar 
are, not only the two pains, but the collateral effects, and the 
general, often indescribable symptoms that attend them; such as 
irritability, mental affections and constitutional derangement of 
various kinds, not easily detailed, yet sufficiently noticed in 
many preceding parts of this essay. But I must trace this con- 
nexion more accurately, and it may form the introduction to an 
account of the less regular varieties of toothach. I shall thus 
be enabled to connect these with ordinary and irregular Neural- 
gia, as I have united the most regular form to the equally regu- 
lar neuralgic intermittent and the common intermittent: and if I 
have formerly succeeded in proving that every Neuralgia, how- 
ever irregular, is but a mode of the regular disease, the same 
conclusion must inevitably be extended to irregular toothach, 
and the proof of which I am in quest will be complete. 

In the common Neuralgia (Tic) of the face, the pain is not 
always that severe and definite one, limited to a particular nerve, 
which it was once supposed; and, however physicians might at 
first have been led to confine that unlucky and mischievous term 
to this definite form, there are very many at least who are now 
willing to allow a wider limit to it, and to admit that Tic may 
exist under at least a few modifications, though this somewhat 
more correct view of the facts is as yet very much confined. 



rEKlODICAL TOOTHACH. 3#5 

In reality, and as I have formerly shown, the Neuralgia of 
the face appears under endless shapes, both as to the place, and 
the nature or intensity of the pain; and I have, I trust, suc- 
ceeded in showing, that all the periodical forms of headach are 
but this disease in fact, and that those pains or headachs may be 
Neuralgias, even when their regular turns have ceased, or where 
they never existed;- just as the admitted Tic may be equally ir- 
regular. 

Now, if it is easy to establish this connexion, it is even more 
so to establish that between common Neuralgia, be it as irregu- 
lar as it may, (Tic) and toothach. Theoretically, and conso- 
nant to all the facts formerly stated and the explanations given, 
they might be expected a priori to be the same; since no one 
point out of all the numerous points of the many nerves which 
supply the face, can be supposed to possess an exclusive privi- 
lege as to this disorder. We should therefore expect to find it 
every where; and, among other nerves, in those which supply 
the jaw as leading branches, as also, further, in those, more mi- 
nute, which furnish each individual tooth. 

Or, to state this more particularly. If the inferior maxillary 
nerve can be affected with Neuralgia in its trunk, that affection 
is, admittedly, not limited to any one point. Let us pursue 
that point as a mathematical fluent. It proceeds along the nerve 
till it arrives at the place where the ramification is given off to 
a tooth; it proceeds even into the tooth, and the name is then 
changed to toothach. But change of name is not change of dis- 
ease: or if it be so, let the opposing assertion define the point in 
this fluxion, where the cessation takes place and a new element 
of equation must be adopted, or where a new disease commences. 
To determine thus, is to be guided by terms, not by facts or 
reasoning: this is the very empiricism of which I have so often 
had occasion to complain; unworthy of science, as it has been 
the eternal obstacle to the progress of physic. 

And, in practice, the facts coincide with this general propo- 
sition. Or, whatever is true of periodical Neuralgia in this re- 
spect, is true of the irregular disorder: and, similarly, as the 
former connects itself with periodical toothach, so does the lat- 
ter with the irregular and more common forms of this affection. 
That is, if a periodical Neuralgia is found to occupy different 
places in the nerve or nerves, from the main branch to its ter- 
mination in the tooth, if it varies its place similarly, or if it ex- 
tends its influence, or, be it severe or otherwise, or be the mode 
or quality of the pain what it may, or let it affect one tooth or 
more teeth, and let those be sound or carious, every one of 
these circumstances will be found in the irregular Neuralgia. 
Or, to conclude, the limits between irregular Neuralgia and ir- 
regular toothach are undefinable, as is true with respect to these 



$2$ PERIODICAL TOOTHACH* 

two disorders when regular: or, out of four forms of disease, it 
having been proved that they are identical when taken by pairs 
in any manner, the whole must constitute but one disease. 

Or now, to state the facts in the ordinary language of practice, 
every part of the face, to any extent, great or small, may suffer 
this pain, in an irregular as well as a regular manner; and in eve- 
ry one of its modes, from the most severe to the most slender 
or diffused; and, equally, all these variations of pain may occur 
in any number of teeth, or in one tooth, and without any re- 
gard to these being carious or sound; though I shall hereafter 
show that there are additional, separate, reasons why a carious 
tooth should more frequently suffer than a sound one. All 
these varieties occur daily in practice; and he must be a very 
inaccurate or unpractised observer, w T ho has not found, in his 
experience in toothach, almost every form that can be conceived, 
from the simplest pain of one tooth, to a distinct Neuralgia, and 
all connected by intermediate links; many more varieties in 
fact than it could serve any purpose to detail. 

Now, had the term Neuralgia been first known, or rather, 
had such a disease as a painful state of a nerve, generically, 
without regard to place, been described, ascertained, and admit- 
ted, had a just medical philosophy preceded popular opinion, or 
rather, had physicians generalized where they have been em- 
ployed in the following petty details, the very term Toothach 
might never have been admitted, at least as a medical and phi- 
losophical one, and the true bearings and nature of that variety 
of Neuralgia would have been understood from the beginning: 
or, had the term Toothach not been made generic, or supposed 
to include and draw a circle round a distinct individual disease, 
still more, had not that term become so inveterately rooted and 
so popular, so united also in the minds of the multitude with 
the false medical opinions which it includes, there would not at 
this day have been the slightest difficulty in persuading physi- 
cians, and the whole world also, to admit that Toothach was 
Neuralgia, and nothing more; and not only a variety of that 
painful disorder in the face, called Tic, but of every other ana- 
logous pain, even to Sciatica. In every point, except place, 
they are, all, the same: but rather than detail all these circum- 
stances of resemblance, since that would be to repeat much that 
has already passed, it will be much briefer and easier to ask the 
opponents, if such there shall prove, to show where they differ. 
It will scarcely' be argued by any physician or anatomist, that 
what is one disease in one portion of a given nerve, is another 
in a different portion, however, it may by the people or the ig- 
norant; seeing that the seat of the disease is the nerve itself, and 
not the part, the tooth, which it supplies: since this would be 
to argue indeed like the vulgar, and as if we should suppose, 



TOOTHACH. 327 

for example, that aneurism of the aorta was a different disorder 
from popliteal aneurism, or gout, in the foot different from gout 
in the hand. 

But to pass from this reasoning as to the identity of Toothach 
and Neuralgia, I shall proceed to point out a few of the peculiar 
and collateral circumstances in which the irregular forms of 
toothach coincide with the similarly irregular forms of admitted 
Neuralgia, that I may draw the resemblance closer, by evidence 
in support of these arguments. If it is generally the more phi- 
losophical proceeding to produce the generalization after having 
detailed the facts, it is often most convenient to lay down the 
proposition first and to adduce the evidence afterwards; particu- 
larly in cases like the present; where we must adopt a super- 
fluity or variety of evidence, in hopes that where our business 
is to convince prejudice, not reason, there may prove, in that 
variety, arguments adapted to the endless varieties of prejudice 
and temper; since even feeble ones often operate here, where 
demonstration itself would fail. 

It is here indeed that the great opposition lies; for while there 
are many who may not refuse, now, to believe that the periodi- 
cal toothach may be a Neuralgia, as it is an intermittent disor- 
der, I have not found one willing to admit that this could be 
true of the irregular toothach. And if I dwell minutely on 
this evidence, it is because I think it one of the most important 
points that can now be established as a new one in physic; if 
not indeed as concerning human life, yet as affecting at least, 
and deeply, human comfort; since the present false theory is 
the cause of an erroneous practice productive of misery and in- 
convenience, which becomes, by its multiplicity and diffusion., 
an immense mass of evil. 

If it should be asserted that this view has already been taken 
of toothach, the answer that it lias not, is completely proved by 
the present practice, which is not even incidental, but univer- 
sal; if it were even not rendered evident by a reference to sys- 
tematic writers. I do not here distinguish Cullen because I 
consider him the highest authority in physic, or from the autho- 
rity of his school having made such an exclusive impression on 
myself as the first teachers usually do on a young mind; but be- 
cause his work is considered a high authority, and because, on 
this disorder, he is, somewhat unusually, clear and decided, 
while very generally followed. And let me also say, if I have 
not already explained myself sufficiently, that, in no case, often 
as I may have selected him as the mark, have I intended any 
properly personal criticism. But while some name, as the or- 
gan of opinions, is necessary, it would even have been disre- 
spectful to have selected a minor one: if also it were not an act 
of justice, to science as to mankind, to note for pernici 



32$ TOOTHACE. 

nious, him, be he who he may, whose authority is likely to ren- 
der his errors doubly injurious. 

The former proof then, in question, is analogous to that which 
was offered before, relative to the division of the nerve in Neu- 
ralgia; and if this particular practice has lately fallen into dis- 
use, not from a better theory of the disease, but from experience 
of its inefficacy, there is not an instance, (I do not mean as to 
individual cases, but as to varieties of the disease,) in which the 
extraction of teeth is not resorted to for the cure of toothach, 
even where they are sound, and in the hands of physicians and 
surgeons of the highest reputation; subject of course to excep- 
tions from various causes, but not one of these arising from a 
just view of the disease. If I could quote a hundred examples 
of even entire ranges of teeth drawn for this purpose, I need 
not allude to a stronger proof of the general error than the case 
of a late esteemed and lamented physician, himself of the high- 
est rank, and surrounded by the whole profession; since, toge- 
ther with a division of the nerve, he submitted to the loss of 
eight teeth, and yet died, it is said, of a disease which there is 
every reason to believe might have been cured under juster 
views, or under which, life at least -would not have been sacri- 
ficed. 

And if it is the contemplation of cases like this, facts in thou- 
sands, if not always equally serious and equally vexatious and 
painful to reflect on, which has made me anxious to enforce my 
opinions throughout this essay, under that conviction of their 
truth which I have attempted to produce in others, so must that 
feeling be the apology, not merely for that anxiety which is per- 
haps too visible, but for the often unphilosophical superfluity of 
manner in which I have adduced and urged the evidences, and 
for a warmth of argument, as for a retrospective criticism, 
which, on any point of cold and speculative truths, I should 
have thought unjustifiable. I cannot calmly see that life has 
been lost and misery produced by want of knowledge, or er- 
roneous views, as in the case in question; nor write without en- 
forcing what I think to be that knowledge, in a far other man- 
ner than I should have undertaken the proof of a problem in 
physics or in the abstract sciences. 

Before, however, I proceed to point out certain collateral re- 
semblances between irregular toothach and Neuralgia, I must 
anticipate the objection which will be again made, as it has been 
to myself, founded on its irregularity: this being, in fact, the 
strong hold of the sceptical, and the only objection of appa- 
rent strength, feeble as it is in reality, which can be urged. 

In treating of common Neuralgia and of intermittent headach, 
I have already shown how often these affections are irregular, 
and what the causes of this irregularity are; as I have equally 



TOOTH ACH. 32 h> 

explained in what they consist, and further shown how often 
they are considered so, when it only requires a more careful 
examination and juster views of the disease, to discover a cer- 
tain regularity under this apparent obscurity. It will be suffi- 
cient to request the reader to turn back to that subject; or what 
is better, to fix in his mind all that has already been said on this 
fact, irregularity, throughout this essay, as well in treating of in- 
termittent as of the several Neuralgiae, and to apply the same 
reasoning to the toothach. It would be mere repetition to tra- 
verse all this ground again; nor would it be any compliment to 
a medical reader, to suppose that he is not himself capable of 
making the application to the cases in question as they may oc- 
cur to him. And if he will keep in his mind these several cir- 
cumstances, I believe, that, with one exception, he will scarce- 
ly meet a case of toothach, however irregular, which he will 
not be able to parallel by a corresponding one of Neuralgia, and 
also of common intermittent; while, most generally, he will be 
also able, with due attention, to give reasons for that irregulari- 
ty. The exception to which I allude is, where a tooth is ca- 
rious; because there is here engaged a separate cause of irregu- 
larity, which I shall have occasion to notice more particularly 
in treating of that variety of toothach; a variety which I rank 
with the Neuralgia from injury. 

Yet I cannot quite leave this subject thus: because, in tooth- 
ach there appears to be one, perhaps two sources of irregulari- 
ty, which are less active in the Neuralgia as it occurs in many 
other parts of the body. 

I have formely shown that in persons susceptible of intermit- 
tent fever, or habitually suffering under it, the application of oc- 
casional causes, such as cold and moisture, frequently induced 
returns of single paroxysms or of entire relapses; and this hap- 
pens in such a manner as often to give the disease a very irre- 
gular appearance. The same is true of Neuralgia under the 
same circumstances; while I have further shown, that, even in 
those not subject habitually to this disease, a single fit, or a few 
paroxysms, will sometimes be brought on by such incidental 
causes; especially by cold, and, as is perhaps especially true, by 
a partial application of this. 

Now the face is particularly subject, from obvious circum- 
stances, to suffer from cold, and from partial cold; while the 
teeth themselves also suffer separately, from familiar circum- 
stances known to every one. Hence an irregularity in toothuch, 
arising from a greater exposure to incidental causes; while the 
fact, as such, is too familiar to require further mention. And 
if derangements of the stomach can act, as is equally familiar, 
in producing common hcadachs, a fact apparently depending on 
tjiat peculiar connexion expressed by the obscure term 8) 

42 



330 / TOOTHACH. 

thy, so do they frequently excite the true, and even the regu- 
larly periodical neuralgic headach in many persons, whether ha- 
bitually subject to Ihese diseases or not. Hence, therefore, we 
may comprehend, how irregularity in common toothach may re- 
sult also from its being partly under the influence of the stomach; 
while the truth of this influence is proved by the well known 
fact that toothach is sometimes actually produced by a deranged 
stomach, and that it is even cured by emetics, though even in 
these cases, the real cure may be that of an intermittent, some- 
times thus removed; a solution which is in some measure corro- 
borated by the parallel effect of this remedy in the neuralgic 
ophthalmia hereafter described. 

Thus then I have shown that the objection against the pre- 
sent view of toothach which is founded on its irregularity, is of 
no force; and I may therefore continue the subject which I in- 
terrupted for the purpose of this statement in anticipation of 
such an opposition; that is, the evidence derived from collateral 
resemblances between Neuralgia and Toothach. 

In numerous cases of common toothach, in every well marked 
and severe one at least that I have ever had proper opportuni- 
ties of examining, I have never failed to trace one or more of 
those symptoms which attend simple intermittent; that is, indi- 
cations, varying in number and degree, of a febrile paroxysm: 
and while those symptoms have been, in general, particularly 
discernible in the chronic cases, or where toothach had become 
an often recurring habit, I have found ample reason to believe ? 
that, wherever the disease has persecuted the patient through a 
long life, the visceral glands have been affected; or, that how- 
ever irregular, it has, like the irregular and chronic intermittent^ 
been associated, whether as effect or coincidence I have already 
declared my uncertainty, with derangements of the liver or 
spleen, or both, but most frequently of the latter. And in some 
cases, this connexion has been so obvious, that while the patient 
was habitually suffering under a palpable or a grievous chronic 
intermittent, the irregular toothach has been associated with the 
disease in all the ways in which the periodical one is, or in the 
exact modes already pointed out as to the several Neuralgias. 

And I have here a collateral remark, which is of some im- 
portance; while I alluded to the same fact as to Neuralgia in 
general, on a former occasion. It is frequently mentioned in 
medical writings, that the pain of toothach, when recurring se- 
verely for many years, destroys the constitution; and this effect 
has been attributed to the severity of the pain. The constitu- 
tional disease here alluded to, is, doubtless, great; but, as I for- 
merly hinted, it is not produced by other pains, nor is there any 
thing in pure pain to account for the species of injury in ques- 
tion. This is one of the errors* far too common in physic. 



TOOTHACH. 331 

which flow from a minute or petty attention to an obvious symp- 
tom, to the neglect of generalization. In these cases, the con- 
stitutional disease in question will invariably be found to be a 
chronic intermittent, sometimes united to visceral affection, and 
to be thus, rather the cause of the toothach than its effects; the 
former being, at least the great disorder, of which the pain is 
but a portion or a symptom. And should the toothach destroy 
a patient, or shorten his days, as it is said to have done, it is 
easy to see to what causes such effects are to be attributed; while 
such erroneous and trifling judgments in cases of such a nature 
as this, are even more unpardonable. But I must withdraw 
from a criticism which, did I pursue it, might involve a censure 
on many to whom I must look with respect on other points, 
however they may have suffered themselves to be misled on 
this one, by following, from habit, minds inferior to their own. 

The general nervous affections which attend common tooth- 
ach, are the same as those which occur in all the Neuralgia?, and, 
similarly, in all the intermittents, whether simple or anomalous. 
It is remarked, even to familiarity, that the pain of toothach is 
peculiarly intolerable, or affects singularly the whole body, and 
the mind also; while, as far as pains can be measured or com- 
pared, it is not equal in quantity to that of wounds, or of va- 
rious painful diseases, which do not equally affect the system, or 
are not equally intolerable and not thus productive of irritabili- 
ty and impatience. Under many severe pains, the mind retains 
its full powers; and when the pain ceases, the inconvenience is 
over; while the former is rarely the fact in the toothach, and 
still more rarely so in the habitual one. This is precisely what 
occurs in every case of Neuralgia, be it wherever it may; and 
hence do the general sufferings, often undescribable, from peri- 
odical headach, Tic, or sciatica, resemble those which occur in 
severe toothach. 

It surely must have been remarked by every one, that the 
physiognomical expression of a person labouring under tooth- 
ach is peculiar, and unlike to that which occurs from gout, or the 
pain of wounds, or almost any other pain. Yet it is the same 
as that which takes place in Neuralgia, as an artist at least will 
immediately discover; and what is more, it will be found to re- 
semble, in an air of peculiar anxiety and of melancholy, united 
or separate, as also at some periods, in a paleness and shrinking, 
and a peculiar greenish yellow or singularly sallow colour, that 
expression which characterizes the fit of intermittent, as I have 
more than once remarked respecting the Neuralgia? in general. 
And if the remark be rather curious or amusing than useful or 
necessary, the character of that physiognomy is well evinced 
as it is accurate])' delineated, by that acute observer of expressi mi, 
Hogarth, in his strolling actors; nor while I point out, in his 



332 TOOTHACfL 

Finchley, another expression for another kind of suffering not 
less correctly represented, need I remind the acuter members of 
my own profession, how often they can themselves decide on 
the exact nature of a painful disease, merely by the face of the 
patient, as I have often decided on the presence of stone, on the 
first, and even on a distant view of the countenance. 

To the peculiar situation of the pain, in the body or substance 
of a nerve, and communicating with the whole nervous system, 
we must probably look for these peculiarities, whatever the 
exact cause may be; and thus the toothach is also often attended 
by hysteria, even amounting to a fit, by lacrymation, or a ten- 
dency to it, and by a species of debility of mind, equally re- 
markable in every Neuralgia, and, in fact, in all the intermittent 
diseases under whatever form. Where dyspeptic and hypo- 
chondriacal symptoms occur in patients subject to habitual tooth- 
ach, as is by no means unusual, the explanation becomes thus 
easy: and thus also we can explain, how it so often happens in 
females, that this disorder, when frequent and durable, is attend- 
ed by menstrual derangements. In reality, in every patient sub- 
ject to frequent and severe toothachs, there is a great deal of ge- 
neral disorder of various kinds; and it can always be traced, 
with due care, to a separate, if, in a certain sense, connected 
constitutional disease, which is that variety of remittent or in- 
termittent amply described in former parts of this essay. 

There is yet one familiar fact occurring in toothach, which 
also connects it with Neuralgia and intermittent; and though it 
may appear trifling as a proof of identity, it is too remarkable 
to be passed without notice. It is removed by charms, a prac- 
tice not uncommon in remote parts of the country: and thus it 
is also that the sight of the operator or of the preparation for 
extraction, often puts a stop to it, and when not habitual, even 
permanently. Thus also is it frequently cured by change of 
place or habits, as it is removed by the occurrence of another 
disease or pain: remedies, all of them, which occasionally, and 
perhaps as often, produce the same effects in other Neuralgias 
and in intermittents. That occupation, an intense resolution di- 
rected to some other, and exciting object, and other similar men- 
tal operations diverting the attention, also dissipate the toothach, 
is not less familiar as a fact, while it continues the analogous il- 
lustration. And if this is fully known to the sufferers under 
this disorder, while, very commonly, exceedingly conspicuous 
when we attend to the effects, relatively, of the solitude of 
night and of the conversation or occupations of the day, it is a 
remark of positive utility, not only in this disease but in ordi- 
nary Neuralgia. And if it is true, simply, that to light a can- 
dle in the night will sometimes remove a toothach, as the ex- 
citement of sending for an operator will often do, much more 



X'OOTHACIL 33% 

effectually, this is but a small advantage compared to that which 
may be derived in a manner which I may call a negative one, 
both in this disease and in Neuralgia. If, in every case, to di- 
rect the attention strongly to any important organ, such as the 
heart or the stomach, will frequently derange its action, very 
easily so when already deranged, though even acting thus when 
those organs are in health, and if this is, actually, a not uncom- 
mon cause of dyspepsia or indigestion, in those empirical and 
selfish persons who are perpetually considering about what they 
eat, or amusing society with their ailments, when at table, so is 
it true that in all the Neuralgias, the pain is materially aug- 
mented by attending to it and talking of it, as it is diminished 
or dissipated by a strong effort of the reverse nature. Hence it 
is that the feeble-minded and the selfish suffer most from all the 
diseases of this class, as do those therefore, impliedly, who most 
torment their physicians; this conduct being quite as much the 
cause of the severity of the disorder, as it is the effect: and 
hence also it is, in a great measure, that females suffer most 
from it, though in them we may also allow somewhat for a ner- 
vous system more irritable. 

How this may be applied to use, I need not say, and lest I 
dwell too long on these resemblances, I will now pass to some 
more local ones; while some of these are of moment, as they 
relate to the errors which have occurred, and do occur, daily 
and invariably, respecting this disease. 

If, occasionally, the pain is confined rigidly to one tooth, a 
fact, however, which occurs chiefly where the tooth is carious 
and the disease is the produce of local injury, it is much more 
common for it to extend beyond that. Thus, like the Neural- 
gia elsewhere, the severe pain will be in one point, of greater 
or less dimensions, while a more moderate pain extends along 
the courses of the nerves, even to great distances. And in some 
cases, where the chief pain is not particularly pungent, the se- 
condary one may be such that the patient can scarcely say where 
it really does lie; while, further, it is subject to wander about 
the face, or to be most intense at times in one part and at others 
in another. Thus does common toothach, like Neuralgia, often 
pass into headach; as, further, the patient may be so equally oc- 
cupied between headach and toothach, as not to know precisely 
by what he is most grieved. In such cases as this, nothing but 
inveterate habit and inattention, added to the weight of a name, 
to that which is always the most weighty argument to the mul- 
titude, could prevent practitioners from referring the disorder to 
Neuralgia instead of toothach; had they indeed known what 
Neuralgia itself was. 

I was about to say that this diffusion of the pain of toothach 
was a much more important object of attention than itmighl 



334 TOGTHACH. 

pear at first sight: I should rather say that it would have been 
one, had Neuralgia itself been better known, and will be one 
whenever it shall be understood. That importance relates to 
the treatment; and though I must in some measure infringe on 
my arrangement by alludiug to this part of the subject partially, 
before I have had an opportunity of treating it generally, it is 
unavoidable; as with this, is almost the whole question of error 
as to practice, concerned. And here therefore, I cannot avoid 
pointing out the whole system of erroneous practice in toothach, 
as without this, I could not in fact finish the history of this dis- 
order, and as I have completed, as far as I here can, all the re- 
marks which I had to make on the history of simple irregular 
toothach as connected with Neuralgia of the same character. 
In this inquiry, I need not separate what belongs to the case of 
carious teeth, or Neuralgia of a tooth from injury, from those 
where no such disorder exists; since this would be to incur re- 
petition to little purpose. It is far from agreeable to be forced 
into a criticism implying a censure so wide; though much less 
unpleasant to argue against general than individual error; while 
it requires some effort of resolution to oppose, alone, a univer- 
sal belief and a practice as universal, and to abide the conse- 
quences that must ensue. 

It is not uncommon for the disease, the Neuralgia, to be si- 
tuated in one or more of the leading branches which supply, by 
their minuter ramifications, a number of teeth. In this case, 
the pain may actually extend into many teeth, or to one half of 
a row, in either jaw, or in both jaws, or to the whole row, in 
either, or even in both jaws; though cases where it occupies 
more than the whole of one row are rare, while this accident 
seems to occur more frequently in the upper than in the lower jaw. 
It may also, in this case, affect but two teeth, or even one; or, 
in such a case as the last, there may be a neuralgic pain of the 
cheek or face, with a decided toothach superadded, in a single 
tooth, which, in the present inquiry, I shall presume to be 
sound. 

In all such cases, varying in many more ways than it is ne- 
cessary to specify, the greatest severity of the pain may be ei- 
ther in the teeth, or, beyond those, in the jaw; while it will be 
sympathetic, or exist as an extension of the principal pain, in 
either of these parts, reversely. But in all cases in practice, 
the teeth are accused as the seat of the disorder, except where, 
among surgeons more anatomical and profound, it is referred to 
a disease in the antrum maxillare, should the seat be the upper 
jaw. A few, with still more profundity, refer it to an abscess 
or a series of abscesses at the roots of the teeth; while there 
may possibly be other still more ingenious modes of accounting 
for such disorders, Unfortunately the existence of such a dis- 



CURE OF TOOTH AC H. o35 

ease as that of the antrum maxillare, serves to cover and protect 
one of these theories as to eases of Neuralgia, as there are also 
rare cases in justification of the other view. 

That such a disorder as I have described, so decided as are 
these varieties, should not be recognised as Neuralgia, might be 
matter of surprise, considering that its characters and the col- 
lateral symptoms are always sufficiently obvious, and, in the se- 
verer cases, so marked and prominent, that any one who had 
ever seen Neuralgia, who had even the idea of such a disorder 
in his mind, could scarcely mistake it. But the surprise will 
diminish when we recollect that even Neuralgia itself is not 
very widely known or recognised as a general disease, or that 
its nature is not understood and its extent and variations not sus- 
pected; that, by many, it is hardly admitted or known to exist 
under any but its marked and popular form of Tic. We can- 
not therefore expect a correct judgment respecting even such 
toothach as I have now described, when there is no general the- 
ory, no foundation on which that discrimination can he founded, 
or no philosophy respecting its seat or nature. 

The practice which follows, is that which might be expected; 
and is that empirical and hereditary practice which, commenced 
perhaps with physic itself, has been continued without inquiry. 
It consists in a number of local applications, generally of a sti- 
mulant nature; or, if there is a portion of the inflammatory ac- 
tion of the membranes present, it may be extended to other 
means which I need not now notice. But the great resource, 
the fundamental remedy, is extraction; and it is now my busi- 
ness to inquire what the effect of this is. 

If excision or destruction of the nerve or of its diseased por- 
tion had proved on trial to be that remedy for common Neural- 
gia which was once hoped, we might have given to those who 
favour or use extraction in the cases under review, the credit of 
some reasoning, and have supposed that, on a similar principle, 
it was their intention to destroy the affected nerves in the teeth, 
But even this much of reasoning cannot be well granted; and 
the abettors of this practice must be content to reflect that they 
hope to pull the disease out together with the tooth, on the same 
principle, if principle that can be called, which exterminates 
the carious tooth, and its pain together, in the same manner. It 
is simply the vulgar and mechanical principle of amputation, 
misapplied; though few perhaps have ever considered the rea- 
sons for a clumsy piece of philosophy, adopted before men be- 
gan to think, and followed because it is established. Assuredly, 
no physician, no one capable of reasoning, would attempt, on 
principle, to remove the pain produced by, and in, a diseased 
branch of a nerve, by removing the teeth which are supplied 
from its minuter ramifications; since it would be as if he w 



oob CURE OF TOOTHACH. 

to attempt the cure of sciatica by cutting off the toes. If that 
is now done daily, it is because the nature and seat of the tooth- 
ach in question have not been understood; and it must therefore 
be expected that the establishment of a just theory will put an 
end to a practice as unphilosophical as it is, generally, ineffica- 
cious, and in every case inconvenient; mischievous and vexatious 
in every way, when the teeth are sacrificed and the disorder re- 
mains uncured, as is the general event. 

And I may add also, that such practices as consist in drawing 
the tooth and replacing it, so as to separate the nerve for ever 
from the tooth itself, or in the destruction of the nerve by 
caustics or cauteries, or in a still more recent invention, which 
divides the nervous branch and suffers the tooth to remain, are 
equally founded on false principles, because, like the division of 
the nerve in ordinary Neuralgia, they cannot prevent the return 
o£ the disease, otherwise than as, in the case of a carious tooth, 
they may, like stuffing or filling the cavity, prevent the future 
operations of the exciting cause, which, in the case of exposed 
nerves, so often induces a fit of the disorder. 

But it is necessary to examine more particularly what are the 
consequences, in practice, of this system. If I lately alluded 
to one case where delicacy forbade me to name the unfortunate 
individual, I could easily detail twenty, thirty, more, cases, 
where entire rows of teeth have been sacrificed to this practice, 
yet without procuring the slightest relief. But there is scarce- 
ly a practitioner who has not met with many instances of the 
same nature; and I need not therefore relate the particulars of 
any one, since most of my readers could supply as much from 
their own experience. Even in common life, there are few 
persons who have not an acquaintance who has thus suffered in 
a less or greater degree; so common are the disease and the prac- 
tice both, and such the perseverance, in what is equally useless 
and injurious, which results from ignorance united to habit. 

If I have used the term perseverance, there is nothing per- 
haps so remarkable in this perseverence in wrong, as when it is 
exerted on a single case: and that this is done daily, is a suffi- 
cient proof of the rooted ignorance on this subject; since I have 
never yet met an instance where the propriety at least of this 
expedient was questioned, where it was not held out as the le- 
gitimate mode of cure, at least in the last resource. Thus, if it 
sometimes has happened that four, five, six, or more teeth have 
been drawn in the course of a few days, the sacrifice has been 
generally made in a much more gradual manner, and weeks, 
months, or even years, may pass before it is completed. It 
might be supposed here, that there would be abundant time for 
reflection to intervene, and that a practice proved to be unsuc- 
cessful on the individual himself, would not be thus persisted 



CURE OP TOOTHACH. 337 

in, even did the practitioner forget that it had rarely succeeded 
in other cases. But so it is; and they who follow this blind 
route must explain their own motives as best they can, since 
they would scarcely thank another for making the attempt. 

As I defer the question of carious teeth for the present, the 
simplest case of this nature is that where there is a pain referred 
to a single sound tooth; in which, if it does sometimes happen 
that the pain is thus rigidly limited, it more commonly extends 
along the cheek or jaw, marking the neuralgic action; while, not 
unfrequently, the real seat of the pain is there, and the tooth 
suffers only by extension of it, as in the other cases of Neural- 
gia formerly described. 

When extraction is resorted to for this kind of toothach, 
there is sometimes a cure, the cause of which I shall hereafter 
attempt to explain when speaking of carious teeth; and every 
cure, of course, unfortunately maintains the practice, while it is 
seldom inquired how often the operation fails. Very common- 
ly, however, it happens, that immediately after extraction, the 
patient perceives that the pain continues, or is in the next tooth 
or teeth; in which case the operator is very often unjustly ac- 
cused of having extracted the wrong one; when a resolute and 
confiding patient will sometimes submit to a second or a third 
loss, though even then the pain will continue. It may perhaps 
continue still in the neighbouring teeth; though more generally, 
where this pain has been limited as to the teeth themselves, it 
disappears from the places of those which have been extracted, 
continuing in the jaw, or in the leading branch of the nerve. 
The toothach is then sometimes reputed to have been cured; 
and the pain of the face is attributed to the operation, or to rheu- 
matism, and is expected to subside: but as it would be endless 
to detail all these events, I shall not dwell on them. 

What is more important here, and also frequent, there is per- 
haps a temporary cure, of greater or less duration: and in a new 
case of Neuralgia, or toothach, as in all other recent cases of 
that disease, as of Intermittent, the first cure may really be a 
permanent one; giving greater encouragement, and productive 
of more and wider evil for the future. But if the disease has 
been of any duration, or repeated, if the neuralgic habit is esta- 
blished, or the patient is in that chronic state of subjection to 
relapses, or of susceptibility, which occurs in all the neuralgic 
and intermittent disorders, the toothach returns at some other 
time, more or less distant; while, very generally, the same re- 
medy is repeated, perhaps with success, possibly not, and the 
more readily if it has succeeded before. Thus, as the Neural- 
gia continues to return, whether spontaneously, as a disease of 
habit, or from the application of casual exciting causes, the same 
operations are repeated in succession, till whole ranges of teeth 

43 



.5ob CUKE OF TOOTHACH, 

disappear before the instrument; until at length perhaps the dis- 
order ceases for life, from those changes in the constitution 
which so often end the habit of all Neuralgia and of intermit- 
tent. 

Independently of the pain of these operations, trifling, it 
must be admitted, when compared to that of the disorder, the 
inconveniences produced by the loss of teeth need not be point- 
ed out, numerous as they are; to say nothing of the consequent 
deformity, which, in the case of young or beautiful females es- 
pecially, is often highly vexatious. And all this is materially 
increased when, as is most generally the case, the cure is not 
effected, or is only temporary. And how common both the 
disease and the practice are, is most palpable; when we scarcely 
meet an individual in society, who has not suffered the loss of 
some teeth in this manner, sometimes indeed justified compara- 
tively by previous caries: though I shall hereafter show that the 
practice is nearly as much misplaced in one case as in the other, 

I know no means of explaining why the neuralgic pain in 
question should be more common in the upper jaw than the 
lower, nor why it should be most frequent, when it affects the 
teeth, in the smaller molares than in any other. Such, how- 
ever, is the fact: and while the foremost of those is the most 
common place of that pain, from this also it extends successive- 
ly backwards to the others; but generally stopping short of the 
last, as it rarely also advances forwards to the canine: it being 
only in the severest cases that the front ones are affected, and 
the lower jaw generally suffering much less, extensively and 
much more rarely. It is further remarkable, that the pain often 
attacks, in succession, the opposite or corresponding small mo- 
lares first; either terminating with them, or gradually extending 
backwards during other relapses, along the other ones on each 
side alternately, and very generally in the upper jaw alone. If 
the ramifications of the superior maxillary nerves throw a sort 
of light on this, it does not explain why any branches should 
be more subject to Neuralgia than others; and we must, for the 
present, rest content with the fact. Hence it is that we often 
meet persons in whom each upper small molaris is wanting, as 
we find others who want two or three more on each side; a 
cause of considerable deformity in young females, in whom also 
this kind of Neuralgia or toothach appears to be more frequent 
than in the other sex. And I believe it is true generally, that 
females are more subject to the several Neuralgias of the face 
than males, perhaps indeed to the disorder in general, if we 
except sciatica, as with them, " nervous" headachs are more 
frequent: a fact arising probably from that greater sensibility of 
the nervous system which shows itself in so many different 
ways. 



CUKE OF TOOTHACH. SSI) 

On this let me make one general observation, which I think 
is of some importance to all those who are subject, to the chronic 
intermittent and neuralgic diseases under whatever form. It 
was inadvertently omitted in the former volume, where it would 
have found an apter place; but it is better that it should appear 
here than be suppressed altogether. 

It is admitted that the irritability (as it is called) of the ner- 
vous system is increased or encouraged by a sedentary life, and 
also by mental rather than bodily occupation. By this also is 
comparative muscular debility induced or increased; as both 
these conditions are remedied by exercise or labour, under the 
usual recommendations as to general health. Hence it is that 
these diseases, on the average, are more severe among those who 
live in the former manner; a fact which assists in explaining the 
greater suffering of females and of the opulent classes: and, 
xvhat is perhaps of much greater importance than any conside- 
ration belonging to Neural giae, such also is very certainly the 
fact as to chronic remittents and intermittents. Thus it is, 
that from the habit of labour, and the consequent general strength 
of the muscles, or perhaps, the irritability also of the nervous 
system hence maintained, the rural population of the pestilen- 
tial districts of Europe are enabled to work during the progress 
of habitual fevers which would utterly disable a sedentary or 
opulent person; while I have often also had occasion to remark, 
as a much more sinking proof, that in the same individual, sub- 
ject to chronic intermittent through years, any one attack during 
the habits of labour or exercise, has produced little disability, 
while the same occurring during a period of sedentary seclusion, 
has, as invariably, destroyed all the muscular powers, or pro- 
duced a state of debility for which no state of the fever itself 
could produce a justification. The value of this fact in practice, 
and the practice which ought to be founded on it, I need not 
point out, as it is abundantly obvious. To return. 

The more severe Neuralgia of the upper jaw affecting the 
teeth, is sometimes considered as a toothach simply, at others 
ascribed to disease in the antrum maxillare, as I already re- 
marked. That extraction, with perforation if necessary, is the 
right mode of cure here, presuming this disease actually to be 
present, is true; but that is a point which might at least be as- 
certained by the loss of one tooth. Yet even such an experi- 
ment is scarcely pardonable; since the characters of Neuralgia, 
and the collateral symptoms as I have already described them, 
are so marked, that the practitioner who commits this error is 
indefensible, though it is made every day. The general prac- 
tice here, as before, is to extract teeth; and when the pain is 
sufficiently severe, the patient sufficiently submissive or resolute, 
and the practitioner sufficiently ignorant, even the whole of the 



34d CURE OP TOOTHACH. 

teeth are sometimes drawn out without mercy or reflection, and 
not unfrequently without producing the cure that has been so 
dearly attempted. In other cases, as I have just remarked, the 
teeth are drawn more gradually, as circumstances happen; the 
failure producing no warning: and thus have I seen a patient 
submitting in succession, month after month and year after year, 
till not one tooth remained; till nothing remained but the pain, 
and which remains at this hour, because it never was in the 
teeth. It is far more unpardonable when this practice is adopted 
in cases where the pain is truly periodical; but so little is the 
knowledge of even that remarkable variety diffused, and so me- 
chanical the routines of practice, that I have seen at least an 
equal number of cases, where all this violence has been resort- 
ed to, and where the disorder was not merely rigidly periodi- 
cal, but even attended with marked intermittent fever; when a 
few days or weeks of arsenic or bark, or of the other remedies 
of Neuralgia were afterwards sufficient to effect the cure which 
all this loss of teeth had left untouched. 

But I have said enough on the subject of these errors; while 
I cannot think that I have said too much, considering the vast 
mass of inconvenience as well as suffering to which they daily 
give rise, and of the termination of which there are no hopes^ 
unless what I have here said shall in time make an impression. 
On the average of cases, perhaps there are three fourths where 
the cure of the pain is not obtained; so that, to the original dis- 
ease, is added all the artificial evil. And even those who do 
purchase the loss of pain by the loss of teeth, pay commonly a 
deep penalty; since, in the same cases, the common remedies of 
Neuralgia would have removed the disorder and preserved these 
organs. If the labour which I have bestowed on even the 
whole of this essay, shall do no more than lead to a reform in 
this department of practice, it will be well repaid; while the 
consciousness of having effected good is the only reward which 
he who does not turn his knowledge to professional purposes 
can ever receive: and if I cannot help feeling that I shall de- 
serve the thanks, at least of the rising generation of youth and 
beauty, though not till praise or censure will alike be indifferent, 
I must, in the hope of that hollow recompense, submit to what 
every man ought to expect, who, by proposing to change a ge- 
neral belief, is thought to insinuate that he is better informed 
than the great multitude. 

That I may not, however, have to recur to the subject of ex- 
traction again, I shall extend these remarks on it, to the case of 
carious teeth; though the nature of this variety of Neuralgia has 
not yet been examined. 

It may happen that every circumstance of pain, and every 
variation that I have described in the case of sound teeth, may 



CURE Off TOOTHACff. 341 

occur in that of carious ones; or, under all the foregoing symp- 
toms, a single tooth, or more teeth, may be carious, while the 
progress and characters of the disease are the same. In reality, 
the caries must be ranked as an exciting cause, not considered as 
a disease, or rather, not as the disease ; a proposition which I 
shall soon explain. 

In these cases, it will sometimes happen that the pain is really 
limited to the diseased tooth or teeth; but it is also very com- 
mon for it to extend beyond that, to the neighbouring or to other 
ones, and also to the nerves of the face, to any extent that it can 
occur in Neuralgia. Whatever be the circumstances, the disor- 
dered tooth is always conceived to be the seat of the disease; 
and there is here therefore less hesitation in applying the com- 
mon remedy, while, in reality, these are the cases whence the 
loss of teeth so general in society chiefly arises, since there are, 
even professed dentists who, from whatever views, are unwil- 
ling now to extract sound teeth. 

Now, if the operation often fails in curing the disorder in 
such cases, it succeeds in many instances; while it is this suc- 
cess, apparently, which has confirmed the practice in question, 
as it has aided in confirming the erroneous theory of toothach. 
It will be useful to inquire in what causes success and failure 
lie; since thus we may approach to a correct view of the utility 
of the remedy, and of its opposed inutility or disadvantages; 
though I can only conjecture what these are, or rather, offer a 
very partial explanation. 

As I shall presently show, I consider that the exposure of the 
sensible interior of the tooth, or of the nerve as it is commonly 
called, which occurs in a perfectly carious one, is an exciting 
cause of Neuralgia in that nerve; or rather, that, in this state, 
the nerve itself is more easily under the influence of injury than 
in its natural condition; while it may also be positively or per- 
manently diseased at that point, as it is in common Neuralgia, 
whatever be the nature of that obscure derangement, and thus 
susceptible of occasional fits of pain, from the same unknown 
and constitutional causes that excite the pain of common Neu- 
ralgia in any part. Some minute portion of the extremity may 
even be in a state of ulceration, or partake in some manner with 
the general ulcer; thus bearing an analogy which I already sug- 
gested, to a similar occurrence in ordinary ulcers, similarly pro- 
ductive of Neuralgia. 

Now, in this case, extraction may cure the disorder in two 
ways. If the exposure of the nerve is merely an occasional 
exciting cause, or if the extremity even partakes of the ulcer, 
and that there is no further disease of the nerve, no fixed dis- 
position to Neuralgia in any other portion of it, or no constitu- 
tional tendency, its effect is to secure that part from future in- 



342 CUKE 0¥ TOOTHACBU 

jury, by removing that body, the tooth, which maintained it in 
a state of exposure, and thus allowing it to be secured and bu- 
ried by the healing process which follows. And this cure is ef- 
fectual and permanent, whenever these favourable circumstances 
are present; though it will still be a question whether that cure 
should not preferably be attempted by the same means which 
remove other Neuralgias, and which rarely fail in new cases, 
however uncertain their success may be in habitual or chronic 
ones. 

The other mode in which extraction appears at times to cure 
toothaeh, is by exciting another pain or temporary disorder, or 
by the shock which the operation and the alarm together give 
to the constitution; effects analogous to those which happen in 
other Neuralgias and in intermittent; as I formerly explained. 
Thus it may, in this way, cure permanently a new disease, or 
one not become habitual; and, on this principle, it also removes 
occasionally the toothaeh where the tooth is not carious; while 
if, in this case also, the Neuralgia is casual, or not fixed, the 
cure may be permanent; just as a permanent cure of intermittent 
is obtained in similar and other modes, when it has not had time 
to become habitual. , But here also, as on the former principle, 
and whether the tooth be sound or diseased, it is a violent and 
an inexpedient remedy; since a Neuralgia that can be cured by 
such a cause, would also be removed by the usual medicineSo 
At any rate, it should be a last resource, even in the case of a 
carious tooth, and far more in that of a sound one. 

On the other hand, where there is a tendency to Neuralgia in 
the habit, or the disease is habitual or chronic, in the form of 
toothaeh or in any other form, it may be the effect of extraction, 
in either way, to remove the fit of pain, or to cure the particu- 
lar paroxysm or series of paroxysms, just as we remove the re- 
lapses of a chronic intermittent; while the disease returns again, 
whenever the unknown constitutional causes, or the fresh ap- 
plication of exciting ones, brings it into action. Here it is, 
that, in the usual inconsiderate practice, the remedy is repeated 
because it succeeded before; and thus it may be repeated again 
and again, because always temporarily successful; and hence 
also it is, that a succession of fits of toothaeh attended by ca- 
rious teeth, leads to that succession of operations which this 
species of success seems, though falsely, to justify as much as 
does the state of the teeth. 

Now, on the contrary, it is here, that better reasoning would 
show that there was a deeper cause present, and would abandon 
a method of cure which is temporary and partial while it is se- 
vere and inconvenient; and hence we should rather derive a 
general rule, though there may be exceptions to it, exactly the 
reverse of the present one. It should be, that wherever., after 



CURE OF TOOTHACH. 343 

one extraction, the disease returns, this plan of cure should be 
abandoned, and the attempt at a real cure of the original and 
fixed disease, made by means of the remedies of Neuralgia; 
while the fits of pain also might be suspended or diverted for a 
time, as they are well known to be in various ways, by any re- 
medies short of extraction. And .there is infinitely less excuse 
for persevering in this practice in those, very common cases, 
where/ oain continues in spite of extraction; as we may then 
be quite c^ain, that, after one failure, it is almost hopeless to 
have recourse again to this method of cure. Least of all per- 
haps is there an excuse, when, from the existence of a great 
number of carious teeth, the whole local evil cannot be extin- 
guished without serious loss and inconvenience, and when, even 
then, we are by no means certain of effecting a cure; as expe- 
rience proves every day. 

If this reasoning be correct as to carious teeth in common ir- 
regular toothach, it is far more unexceptionable in the case of 
the periodical disease; since the cause is then so much more ob- 
vious, and since the remedies of intermittent and Neuralgia are 
also more efficacious than in the other varieties: as is true of al! 
the modes of those disorders, always most amenable to remedies 
when most regular. Nor in any case, should extraction be re- 
sorted to until the remedies of Neuralgia have been fairly tried; 
as they never are, since the disorder as yet is not known as such: 
while of their efficacy in all the varieties, I have experience 
which cannot deceive me. 

It will be plain now, that the extraction of a tooth cannot 
very often be a justifiable practice on account of pain: while I 
am fully convinced that were this disorder always treated as a 
Neuralgia, empirically, and without consideration of causes, or 
varieties, or aught else, without in short reasoning at all on the 
subject, (which to the multitude is the most easy and acceptable 
manner,) thousands, or rather millions of teeth would be saved, 
and perhaps also thousands of cases of toothach cured, which 
are now the torment of thousands in spite of extraction. And 
as it is found that Neuralgia and intermittent are most easily 
cured, even permanently, when recent, or before habit has ren- 
dered them chronic and refractory, so it would be the right po- 
licy to commence with this system at once, and ort the first ap- 
pearance of the disease; since we have much less hope of bene- 
fit in ancient cases. 

It is easy, however, to imagine a case where early extraction 
might be advisable; and it is perhaps the only one in which it 
can really be recommended, while it would require some atten- 
tion to ascertain the propriety. If it should appear that a new 
case of toothach, and, perhaps especially, in a young person, is 
produced absolutely from a badly carious tooth, and from its 



344 TOOTHACH FROM CARIES. 

exposure, it is possible that its frequent recurrence from exter- 
nal exciting causes, might induce the habit of Neuralgia in the 
constitution, and thus lead to an inveterate disease. Should such 
a case occur, and prove refractory to the remedies of Neuralgia, 
or to other local means, it might be prudent to take away the 
tooth, for the purpose of securing the nerve; and thus, by re- 
moving at once the only or chief cause, ensure the avoidance of 
the evil to be dreaded, and the permanent cure. Such accura- 
cy of views can scarcely, however, be expected while this dis- 
ease is to be judged of by mechanical dentists; and it would un- 
questionably be for the interest of the public, to reserve for their 
medical attendants what belongs to diseases, and confine the me- 
chanics to their own, proper, sphere. At present, no more in- 
quiry or judgment is exerted on a case of toothaeh than on the 
cleaning of a tooth; and assuredly, a constitutional disease such 
as, I trust, I have proved this to be, is not one that is very like- 
ly to be understood by the persons thus employed, or, even if 
they were really better informed, in the way that they are con- 
sulted; since that consultation is rarely more than an order for 
extraction. As to other reasons for extracting carious teeth, it 
is not my intention to interfere in this department of surgery; 
however convinced I may feel of the groundless or false reasons 
so often urged in defence of it. 

I have now, from the obvious necessity of inverting the or- 
der of this discussion, to save repetition, said so much respect- 
ing the toothaeh as it arises from carious teeth, that I have left 
little to add on that subject; while that which remains relates 
chiefly to their mode of action in this case. 

I snowed in a former part of this essay, that the local injury 
of a nerve could produce a regular periodical Neuralgia; while 
I further suggested, what indeed is almost obvious, that the ir- 
regular pains produced by such a cause ought also to be consi- 
dered of the same nature. Now these are cases exactly analo- 
gous to the toothaeh from a carious tooth; and thus we can see, 
how, from such a cause, even a periodical toothaeh might be 
produced. The extremity of the ramification supplying the 
tooth is, if not an injured nerve, an exposed one, susceptible of 
occasional injury, and also, it is probable, of inflammation: 
while it is not very improbable that the exciting disorder in the 
nerve in every case, the permanent cause which produces occa- 
sional fits of pain, is, if not a species of inflammation, some- 
thing analogous to it. Hence, if the prick of a needle in the 
finger, or any other injury, can excite true Neuralgia, in the 
same or in a distant part, as I have shown that it can do, it is 
easy to imagine how, not only simple toothaeh of the part but, 
even Neuralgia in the face, may be produced by a carious tooth. 
The analogy is perfect, or rather it is an absolute identity: and 



TOOTHACif FROM CASHES, 345 

it is one, further, which serves to confirm the whole theory of 
toothach as I have now given it; so far from controverting it, as 
has been retorted on myself. And in such a case, should any 
tendency to the disease be present, or should there be a previous 
habit of Neuralgia in the constitution generally, or in the neigh- 
bouring parts, such a cause, permanent at once and occasional, 
might be the perpetually renovating occasional cause of a se- 
rious disorder, of which it would be esteemed the sole one. 
And the perpetual obstacle to conviction in this case, is nothing 
but the simplest of all fallacies, a term: or it is the mistaking of 
one part for another, or the substitution of the visible screen of 
an object for the object itself which it covers. Let the objector 
but once persuade himself, or recollect, that a tooth is insensi- 
ble, that it is nothing, that the nerve is every thing, the seat of 
life as well as of pain, and he can have no further difficulty; 
since it must be indifferent where that nerve lies, and since it is 
the same law, operating on the same thing, but in a different 
place. 

I have but one more remark to add before I pass from a sub- 
ject, which, if it has occupied much space, must seek its apo- 
logy in its former obscurity and in its importance. Carious 
teeth do not invariably produce toothach, far from it; even 
when we are sure that the sensible parts are equally exposed, 
and when the proof of this is perfect, from the pain which an 
injury, or the contact of a stimulating substance produces. So 
far from that, we find thousands wasting away through years, 
and with the sensible part exposed the whole time, and yet 
without exciting pain; while, when excited, even violently, by 
accident or design, for a few minutes or hours, it terminates, 
not to recur again but from fresh injury. The most common 
reasoning should therefore show, that the disease does not es- 
sentially consist in such exposure or injury, but that something 
else is present, and that this is but an occasional cause. That 
fundamental cause lies in the nerve, or the nervous system, as 
in all Neuralgia?: and while this indicates the want of observa- 
tion under which the disorder has always been considered and 
treated, it aids in confirming the views which I have held out 
respecting its nature, its constitutional nature, if I may use that 
term: as it justifies the mode of treatment by which the cure, 
in the view that I have taken of it, ought to be attempted. 
What else relates to that, however, beyond what I have alrea- 
dy been compelled to remark, I shall defer till I have consi- 
dered the last variety, the inflammatory or rheumatic toothach, 
or the rheumatism of the face. 

Yet not without making one remark. Should I propose to 
treat the toothach from caries by the same remedies which are 
resorted to for Neuralgias, or for toothach without caries, it 

44 



346 



BHECMATIC TOOTHACH. 



a very natural objection to ask how a cure can be thus expected 
when the disease is local, or thus far at least, of a local nature. 
The answer ought already to be obvious; and it is, that Neural- 
gias arising from an injury to a nerve, in a finger, or elsewhere, 
is thus as readily cured as any other variety. All that can be 
admitted, therefore, in this case is, that if the nerve of the 
tooth is injured or exposed, it may renew the disorder again, 
after having been removed; as being an exciting cause always 
ready to act: though it is far from improbable that a permanent 
cure may be effected by the operation of these remedies on the 
nervous system at large, since I have just shown that some con- 
dition of this must conspire with the local disease in the pro- 
duction of toothach. 

I formerly showed that it was a frequent effect of Neuralgias 
to excite an action in the minute arteries, tending in some cases 
to inflammation, and as I shall hereafter show, sometimes actu- 
ally producing it. I have further compared, and must for the 
present purpose compare, again, that action of the arteries in a 
part, to the effect which takes place, of an analogous nature, in 
the whole arterial system during the paroxysm of intermittent. 
I have also shown, that in the Neuralgia of the rectum, and in 
the periodical beadach, the neuralgic pain is confined to the mi- 
nutest ramifications of the nerves, avoiding the larger branches; 
and that in this case also, the arteries of the same parts put on 
an inflammatory or excited action. It has further, and lastly 
been shown, that in intermittent, periodical and transient rheu- 
matism, or inflammation, can take place in a part, without de- 
cided neuralgic pain, as such inflammation may also become per- 
manent; and I have pointed out the general analogy of these in- 
flammations, including those of the stomach and bowels. This 
I am inclined to distinguish by the term neuralgic inflammation, 
in all cases; conceiving that, even in the last, mutually connect- 
ed, and unlimited with respect to each other, as all these are, it 
is from such an affection of the very minutest ramifications sup- 
plying the capillary arteries, that this effect proceeds. 

But whether we choose to apply the term neuralgic or not to 
this species of inflammation, its connexion with intermittent fe- 
ver has been amply demonstrated; as its similar connexion with 
Neuralgia will be more fully shown hereafter; while it is also 
familiarly subject to paroxysms with intervals, as regular and de- 
cided as are those of the best marked intermittent fever. But 
it is sufficient to remind the reader of these facts; while it ought 
to be superfluous to repeat and array them again, for the pur- 
pose of illustrating the parallel disorders under review, or the 
rheumatic toothach under its several forms. 

Not to refine more than is necessary, it will be sufficient to 
consider the rheumatic disease in question under two varieties; 



RHEUMATIC TOOTHACH. 347 

teamely, as connected with a carious tooth, and as independent 
of that; while, under each, it may be strictly periodical, or ir- 
regular, as is the simpler toothach itself. 

But as I have already described the various modes under 
which mere toothach is periodical, as also its irregularities, 
while I have further detailed the collateral symptoms which at- 
tend it and mark its character, and moreover, attempted to ex- 
plain the causes of such irregularities^ it will be unnecessary to 
go over all this ground again, since the statements then made 
apply equally to the rheumatic or inflammatory form of the dis- 
ease, and that, whether there is a carious tooth present or not. 

Supposing a carious tooth to be present, there are two modes 
in which the rheumatic inflammation may occur. If the pain 
has commenced in the tooth, the inflammation may be deter- 
mined or produced by that; and we may then conceive it as the 
produce of the Neuralgia in the main nervous branch supplying 
the tooth; an excess of that action which so generally occurs in 
the neighbouring vessels in every Neuralgia. But the rheuma T 
tic or inflammatory action may also be the prime or leading dis- 
order, while the pain of the tooth is produced by its extension. 
In this case we may compare it with the local rheumatisms for- 
merly described as connected with intermittent, of which it is 
in reality a frequent variety. 

If, on the other hand, there is no carious tooth, the rheuma- 
tic inflammation in question bears still more strongly the marks 
of an original disease, while in this case, its characters and ori- 
gin are those just described. And here, if it is most generally 
a simple disease, a merely painful state of the membranes of 
the face, attended with inflammation and swelling, or not, it 
sometimes also excites a distinct neuralgic pain in addition, or 
else appears to originate in one; such cases being exact paral- 
lels to those just described where a carious tooth is present. 

Having made these necessary distinctions, what remains of 
the description may be considered as appertaining to all these 
varieties; as it is unnecessary to prolong this account by a fur- 
ther multiplication of variations. Generally, the disease is the 
same under all its forms; and the important object here, is to 
establish that generic character, for the sake of the practice de- 
pending on it, as well as for the purpose of completing the theo- 
ry of this branch of the Neuralgia. 

In the rheumatism of the face, the inflammatory state is some- 
times so imperfect and transitory, that it would rather be consi- 
dered a painful disease than an inflammatory one; and this is 
particularly the case where it is periodical, or paroxysmatic, un- 
der any form, however irregular. In such cases, it approxi- 
mates intimately in its character to pure Neuralgia; and may, 
in fact, be considered as a Neuralgia extending through a great 



348 BHEUMATIC TOOTHACH. 

number of the very minutest and unassignable nerves that supply 
the membranes. It is, but for its place, a headach, or the theo- 
ry of the disease, mutatis mutandis ■, is that of the analogous 
headachs; while, in practice, the two are often so united, or the 
limits of separation so loosely drawn, that a patient is sometimes 
at a loss which name to give to his disorder. If these are the 
cases in which it is most apt to be regularly periodical, they are 
not the exclusive ones, as I shall presently show. 

When the disorder proceeds to actual inflammation, it pro- 
duces those well-known effects which I need not describe; and 
in these cases the disease generally lasts a definite time without 
interruption; though even here it is common to find quotidian 
exacerbations of the pain, and sometimes also, of the swelling* 
Yet as I just insinuated, even this disorder is sometimes strictly 
periodical; as I have known some cases where a distinct swell- 
ing occurred daily, subsiding again; in two of which the disorder 
under this form lasted for some years, but with those intervals 
which occur in almost all very chronic intermittents. And in 
both of these, if there were symptoms of an equally regular in- 
termittent fever present, the disease was, in one, not only a 
marked quotidian, but one of an extremely severe character, 
enduring, with interruptions, for seven or eight years: while 
the swelling and pain of the face, equally regular for the most 
part, often terminated in abscesses in the gums, such as are of 
familiar occurrence in this disorder. It scarcely, however, re- 
quires such cases as this, to prove the neuralgic character of this 
disorder, and its connexion with intermittent. All the circum- 
stances show that the view here given is a just one; and who- 
ever shall now study the cases that may come under his hands ? 
with this theory, will soon convince himself that it is so. 

In the ordinary current of practice, this is the history and ex- 
planation of those very common cases, where we find certain 
persons subject, as it is termed, to swelled faces; and if any phy- 
sician will register, after careful examination, and afterwards re- 
view a certain number of those cases, he will not fail to become 
convinced of all those peculiarities by which the disease is asso- 
ciated in the manner that I have been here attempting to prove. 
Let this however be done with the intention of trying the truth 
of this theory; without which, the characteristic symptoms 
might be overlooked, as, under habit, they so easily are. And 
as a proof of this, of the very cause which has so long thrown 
obscurity over this as over all the Neuralgise, I may observe 
that in the case to which I have just alluded, where the patient 
was subject to " swelled face" during a period of more than se- 
ven years, almost daily, so as to be utterly disabled, the inter- 
mittent nature of the disease, and the fever connected with it, 
had oever once been observed; while a mere cross-examinatioE 



RHEUMATIC TOOTHACH. 349 

by means of a letter, was sufficient to detect a truth which was 
immediately confirmed by the entire cure of the disease through 
arsenic and bark. 

The formation of abscesses is perhaps the most singular cir- 
cumstance attending this inflammation; while it is one that I do 
not pretend to account for, occurring as it does when a tooth is 
not carious, though far from frequent in this case. It is a fact 
that might be objected against the present view of the disease: 
but it is plain that it is of no peculiar moment as such, since 
the same objection would lie on the view of its being a rheuma- 
tism, seeing that there is no other proper rheumatism which ter- 
minates in this manner. If we cannot exactly account for it, 
we must suppose that it depends on some peculiarity in the 
structure or nature of the gums, not yet ascertained; a peculia- 
rity which is evinced by the enormous length of time during 
which abscesses will continue to form in them, and in one point; 
a fact to which we have no exact parallel elsewhere, of which I 
know. On this subject, I may indeed add, that I was long fa- 
miliar with a case, where an abscess on one point of the gum, 
not equalling a pea in dimensions, collected and broke, every 
second or third day, during; the space of twenty years. Yet 
let it be remarked as to this termination of the neuralgic or rheu- 
matic inflammation, that the same event, abscess or suppuration, 
occurs also in the analogous inflammation of the eye: so that 
those physicians who consider this a rheumatic disease, will be 
as much at a loss to explain this peculiarity as myself, when I 
call it a neuralgic one and associate it with the disorder under 
review. 

I have thus finished all that I think it necessary to say re- 
specting the forms of toothach; and after the details that have 
been given, it can scarcely be necessary to offer further proofs 
of the truth of the theory which I have here laid down. The 
occasionally periodical or intermittent character of the disease 
in all its forms, has been established, while its actual connexion 
in some cases, even with intermittent fever, has been shown: 
nor are there any irregularities in it which are not equally found 
to occur, in chronic intermittents especially, and particularly in 
the anomalous varieties, or in those that are attended by local 
symptoms. On the other hand, its identity with Neuralgia has 
been similarty and even more clearly proved; while the exami- 
nation of cases of this disease in other forms, will show that no 
anomalies or irregularities occur in toothach, that are not simi- 
larly found in every Neuralgia; no other at least than those 
which can be explained by the circumstance of frequent local 
injury arising from a carious tooth; while this is also counte- 
nanced by the parallel cases of Neuralgia in other nerves, arising 
from similar injuries. But 1 shall leave these facts and argu* 



350 TOOTHACH. 

ments to make such impression as they may; aware that, even 
should they be successful, it will require a long time to over- 
come prejudices so firmly rooted, as well in the minds of me- 
dical men as in those of the public at large, or to establish this 
as a branch of a general theory, when the very basis itself la- 
bours under the misfortune of novelty, and must also work its 
own way to acceptance. 

Let me now, however, in concluding, sum up the chief ar- 
guments as to toothach, in a condensed and somewhat more lo- 
gical manner, since they will thus be more impressive than un- 
der the diffused illustration which I have been obliged to use in 
explaining the connexions of all the varieties of this disorder. 
That they involve a series of pure syllogisms, ought to render 
them convincing; that this will do so, is a very different as- 
sertion. 

Neuralgia is a pain occupying some point in the nerves of 
the face, among others; and it may occupy any point in any 
large branch which supplies the teeth, among other nerves of 
the face. The pain which it produces is the same pain, what- 
ever be the nerve or part of that nerve affected. The pain of 
toothach is the same pain, and it is seated in an ultimate extre- 
mity of the branch which supplies the teeth, or in more. If 
that pain is not Neuralgia, then it must follow, that although 
every other point of that nerve, when pained, is suffering from 
Neuralgia, let that pain exist any where, from the brain even 
to the extremity, the very last, ultimate, point thus suffering, 
suffers from a different disease. Reductio ad absurdum. 

Neuralgia is regularly intermittent and periodical, or it be- 
comes irregular, under various modes, and from causes, of which 
many are assignable. The same is true of toothach. Neural- 
gia is often, or perhaps generally, attended by a peculiar consti- 
tutional affection, ascertained to be a chronic intermittent, and 
when highly marked, there is a febrile paroxysm accompanying 
the pain. All this is true of toothach. Neuralgia alternates 
with intermittent fever, by relapses; so does toothach: it alter- 
nates with it by paroxyms, and toothach does the same. And 
in both, the types may be quotidian, tertian, and double tertian, 
or perhaps more; while, in both, the disease may be similarly 
doubled; or, being a double tertian,' may consist of a paroxysm 
of the pure intermittent on one day, and of the Neuralgia, or 
of the toothach on another. 

Neuralgia is attended by heat, and by excitement of the mi- 
nute arteries, accompanied by general diffused pain, or irritabi- 
lity, or both; and so is toothach. Neuralgia and toothach are 
united, or simultaneous; or, the pain, and the place of the pain 
may be such, that neither the physician nor the patient can de- 
termine what the disease ought to be called. Neuralgia passes 



CURE OF TOOTHACH. 351 

into, or produces toothach; and, reversely, toothach passes into., 
or produces Neuralgia. The two pains alternate, in various 
modes; or that which was Neuralgia at one period, be that of 
day, hour, or minute, or even instant, may be toothach in the 
next; or the reverse. 

Neuralgia is produced by the injury of a nerve. So is tooth- 
ach; and this is the case of a carious tooth. And if toothach 
from this cause is especially frequent, it is that the caries of a 
tooth is very common; and that there are not, in external cir- 
cumstances, or in the body, any frequent means of thus injuring, 
either through accident or disease, the branch of a nerve else- 
where. 

Toothach, when regular, is cured by the same remedies as re- 
gular neuralgia. In many instances it is thus cured, even when 
irregular: and if such cure is not more frequent, it is because 
physicians have not thus attempted it: not having taken that 
view of this disease which I have here endeavoured to establish. 

I might now treat of the cure of toothach separately, before 
proceeding to what little remains respecting the diseases of this 
class. But I have already examined the most generally re- 
ceived remedy, viz. extraction, and attempted to ascertain both 
its value and its evils: and, as far as this disorder may find a 
cure from the general remedies of Neuralgia, it will save repeti- 
tion to defer the question till I treat of this subject generally. 
As to the ordinary local remedies in common use, I have not 
much to remark; being willing to admit nearly the whole as 
occasionally useful, and having little or nothing to say respect- 
ing them which is not known to every one. If, however, it 
may seem incumbent on me to explain why the local application 
of stimulants should remove a Neuralgia, or the toothach viewed 
as such, it can apparently be accounted for on the same princi- 
ple as in intermittent fevers or ordinary Neuralgias, where a 
powerful stimulus to the nervous system, or any strong counter- 
impression, so often suspends or removes a paroxysm; while, 
in so doing, it will often stop an entire relapse, or, in a recent 
case, even cure the disease. 

If intermittent and toothach both can be cured or suspended 
even by charms, there is no difficulty in accounting for the ca- 
sual success of every remedy that has ever been found to suc- 
ceed in toothach: while we thus account also for the occasional 
success of empirical remedies beyond number, and for the re- 
putation which they have hence acquired. I would only re'- 
mark respecting these local remedies, and of one of the most 
popular, that as blisters very generally aggravate a Neuralgia, 
when applied near the affected nerve, thus are they frequently 
equally pernicious in toothach, as many persons have doubtless 
experienced; though probably judging them inefficacious rather 



352 CURE OF TOOTHACH. 

than mischievous, and attributing the increase of pain to an in- 
crease of the disease. And I believe also it will be found, that 
they are most injurious in the rheumatic toothach, though fre- 
quently resorted to by mechanical practitioners; as the minute 
vessels are then precisely in that state of action which blistering 
tends to augment rather than to subdue. And if less injurious, 
I am inclined to pass the same judgment on the other stimula- 
ting applications so commonly adopted; while when warm wa- 
ter is found useful, it is a fact connected with the remedies of 
all Neuralgia, which I shall hereafter point out. 

I need only further add, that of all the local applications used 
for toothach, though in reality applicable, properly, only in the 
case of a carious tooth, or at least seldom succeeding in other 
cases, the most successful are the essential oils, such as those of 
cloves and cinnamon, applied to the sensible interior; which by 
exciting a violent opposed sensation in the nerve, frequently re- 
move the neuralgic pain. With respect to the treatment as it 
may be conducted by the rules for neuralgic cases in general, 
he who becomes master of this subject will easily judge how 
they may be applied, and under what exceptions; while I may 
add, that I have, by means of them, cured innumerable cases, 
thus preventing further extraction, or saving hundreds of teeth; 
and very many, where, after the freest and most destructive use 
of this mistaken and vexatious remedy, the disease still conti- 
nued unabated. And if this preservation of teeth destined to 
extraction has been, in my practice, most extensive in young 
persons, and above all in young females; this is explained by 
that greater frequency of this disorder in them, already noticed, 
and by the fact, that in the youthful, the habit of Neuralgia can- 
not be so firmly established as in the aged. To detail instances 
of this nature would be abundantly easy; but as it would be 
only to a$d the individual evidences to the general one already 
deduced from those cases, it would scarcely justify the space 
which it would occupy. 

But before I entirely quit this subject, it will not be irrele- 
vant to add, what I have had frequent reason to suspect, that it 
was not only part of the neuralgic action on the nerves of the 
face to render the teeth carious, but that this was a common 
disease in marshy situations. It would not be a very unreason- 
able conclusion, whether it were absolutely proved or not: since 
while it is the effect of that action to diminish the energy of 
nerves, even to the production of palsy, as is also true of inter- 
mittent in general, it is not difficult to understand how the en- 
tire death of a part possessing naturally a very feeble portion of 
life, might be the consequence. As is usual, however, in the 
whole history of these disorders, the past ignorance and inat- 
tention deprive me of a sufficient command over special exam- 



NEURALGIC OPHTHALMIA. 353 

pies in proof, though I find the broad fact which I have already 
stated, to be a general remark of many travellers, as I am equal- 
ly confident of it within my own narrow range of observation. 
But I cannot help mentioning one very pointed case, observed 
by Captain Smyth in Sardinia, though I will not pretend to de- 
cide on its value. It is, that at Villa Cidro in that island, where 
the men reside invariably in the mountains, while the females 
alone descend to the pernicious plain below, which they are ex- 
clusively employed in cultivating, all the latter are noted for 
bad and spoiled teeth, when the men have no marks of the 
same kind, but, on the contrary, are noticed for good ones. 
And if it will give any support to the opinion of the at least 
frequent dependence of toothach on Malaria, I may remark, 
what I doubt not others will confirm, when they shall carefully 
review their own experience, that not only does toothach abound 
most in low and damp situations^ but in east winds, or general- 
ly, under all the circumstances which produce intermittents, 
even as it relates to season, and also to geography: and what is 
equally remarkable, that seasons, or years peculiarly noted for 
intermittent and remittent, such as have been the immediate 
years 1826 and 1827, are also peculiarly productive of cases of 
toothach: just, in fact, as they produce all the Neuralgias, and, 
very remarkably, the Neuralgic Ophthalmia. 



CHAPTER XVIII. 



On the Rheumatism of the Eye: or the Neuralgic Oph- 
thalmia. 

In conformity to the plan which I have already followed, in 
making use of such popular names as happen to exist, for the 
disorders which I have here brought into notice under new views, 
I have adopted the above term for a species of ophthalmia, which, 
if not so often discriminated from others as it ought to be, is at 
least known under that name, and under no other. Were I to 
propose a term corresponding to my own views of the disorder, 
I should call it, as I have suggested in this title, the Neuralgic 
Ophthalmia; as I hope to prove that it is a variety or species un- 
der the general disease which I have here treated. And as the 
opinion that it was such, had been formed from my own obser- 
vation, as long ago as I had first adopted the whole of the views 

45 



354 NEURALGIC OPHTHALMIA, 

in this essay, or almost ever since I knew what physic was, 1 
have had abundant opportunities of studying it on this theory? 
and of confirming that belief by an ample experience. If others 
however should doubt that it is so common a disease, I must re- 
ply as formerly, that it has not been sought for; or rather, that 
it has been for ever confounded with common ophthalmias, as 
it is still, daily: and that as soon as it shall be thoroughly dis- 
tinguished and understood, and whenever practitioners shall be- 
gin to discriminate better, they will find that there is no want 
of cases. And lest this change of name and change of theory 
should be supposed a frivolous innovation, I must remark that 
it is of the highest importance as to the cure of a very common 
disease, maltreated, now, even under the term rheumatism of 
the eye, and far more so when confounded with common, or as 
happens also, with contagious ophthalmia: while, under such 
erroneous treatment, the loss of sight is by no means uncommon; 
to say nothing of minor inconveniences, and of some even more 
serious consequences. 

In some places, this ophthalmia is arranged by Sauvages with 
his Migraine or Hemicrania, under the term " migraine des 
yeux," and in others under other titles; proving his want of 
correct notions respecting it: while Cuilen does not take the 
slightest notice of it in his very meagre and superficial descrip- 
tion of the general disorder. The former remarks that it pro- 
duces inflammation in the globe of the eye, terminating in a 
confusion of the humours and in suppuration; unaware apparent- 
ly of the milder cases, yet, in another place, noticing its ten- 
dency to return in the second eye after destroying the first. In 
St. Yves and Maitre Jean, some cases of it are described by the 
term amaurosis; that expression apparently meaning the de- 
struction of the humours: while it is remarked that it endures 
for months or years, that it is attended by fever, hemicrania or 
elavus, want of sleep, and giddiness, and that it attacks one eye 
after the other: while the former oculist, adopting the usual re- 
source which ignorance has resorted to in so many more of these 
disorders, proposes to prevent this second attack by extirpating 
the first eye. I did not say too much when I said that had the 
surgical sect believed the sciatica to be Neuralgia, and dared to 
extirpate the sciatic nerve, they would equally have had recourse 
to their panacea, the knife. 

Among many casual notices of this^peeuliar ophthalmia, and 
unsatisfactory as casual, I must, however, distinguish the essay 
of Wardrop; the first, I believe, through which the attention of 
physicians was fairly called to it. To praise that essay for the 
accuracy of its description of a much neglected disease, is but 
to agree with all who have read it: yet I should be negligent of 
my duty did I not remark, that however perfectly my able friend 



NEURALGIC OPHTHALMIA. 355 

has seen and discriminated this variety, his account is limited to 
the severer cases, and that he has not appeared to be aware, in 
bis essay, whatever may be the case otherwise, either of the 
slighter and less marked, or even of the chronic, varieties, or 
of the extreme prevalence of this peculiar species; and that, in 
consequence, there is almost as much error prevailing, in prac- 
tice, respecting it, even under the name which he has adopted, 
by those who have had the advantage of his experience, as there 
was before. Thus also I perceive no notice of its properly in- 
termittent and alternating characters; while with respect to other 
portions of the description, such as the general fever, the bilious 
symptoms, the decided neuralgic and periodical pain, to which I 
may also add the utility of bark, I should desire no other evi- 
dence to prove that it demands the term which I desire to ap- 
ply to it, and that it is in reality a mode of Neuralgia. I shall 
however be able to produce much further evidence of its con- 
nexion both with that disease and with intermittent: and if I 
were inclined to express any surprise that so acute and expe- 
rienced an observer had not formed the conclusion to the very 
verge of which he has approached, I should suppress that by 
recollecting, that in this as in every other disease which I have 
here described under this leading character, the foundation and 
cause of all the error must be sought in the want of a correct 
and broad view of the fundamental disease itself: Neuralgia. 

The descriptions to which I have alluded, with others that I 
need not point out, confined and imperfect as they always are, 
do not exempt me from the necessity of giving my own view 
of the disease: since it is only by describing it in the manner 
which 1 conceive to be more correct, that I can hope to establish 
what I consider its true theory: while I must adopt a mode of 
description which will convey the proofs together with the facts 
themselves. 

I must however further remark, that while my own views of 
this disease have been derived solely from my own observations, 
I have recently found, in reading where I had formerly neglect- 
ed to read, that some writers have noticed a connexion between 
ophthalmia and intermittent. Among these, I may name Mor- 
ton, Strack, and Monfalcon; the latter further remarking, that 
this inflammation is very common in those districts of France 
where Malaria abounds, and that it is there very apt to termi- 
nate in opacities; a fact which I shall also point out hereafter. 
This last observation confirms, as to this particular affection at 
least, the opinion here every where stated, that all these lo- 
cal disorders are produced by Malaria, whether always so ge- 
nerated or not: but it is important to observe, that while the 
French writer does not detail the characters of this ophthalmia, 
sior apparently perceive that it is a localized intermittent the 



356 NEURALGIC OPHTHALMIA. 

German physician and Morton also, as far as I can discover, no- 
tice the disorder solely as accompanying severe and marked in- 
termittens, as an occasional symptom or addition; not seeming 
to be aware of an ophthalmia of this character with little or no 
distinguishable fever, nor, either here or any where else, taking 
any notice of the numerous analogous diseases of which I have 
treated. If in the Med. Chir. Trans., I find a record of cases 
occurring after delivery, where the confinement of the inflam- 
mation to one eye seems to point to the same disease, the whole 
circumstances are not sufficiently detailed to render such a judg- 
ment safe: nor will I venture to comment on such other recorded 
cases as I may suspect to have belonged to this variety, since I 
hope that my readers are now fully capable of doing that for 
themselves. 

Like all the neuralgic diseases, this one sometimes occurs un- 
der a periodical character, while at others it is irregular. And 
if it is more frequently of an irregular character, or not distinct- 
ly paroxysmatic, it is scarcely more so than its nearest analogy, 
rheumatism of the face; while there are often symptoms also 
present, which mark accessions and intervals, even though the 
inflammation itself should be persistent. I shall, without any 
formal division, describe it now under these variations; but must 
first say a word respecting its apparently exciting cause, lest this 
should be objected to the supposition that it belongs to this class 
of disorders. The same remarks will apply to the rheumatism 
of the face; and I reserved them to this place, that I might not 
have to produce them twice over. 

It is observed, and perhaps very commonly with truth, that 
this ophthalmia is produced by exposure to cold winds, very 
often by partial cold, and very particularly, as it is thought, by 
a sudden impulse of the east wind on the eye, or face. The 
popular term in this case is, a " blight;" while as it is not unu- 
sual for the east wind to be especially attended by dust, this is 
often esteemed the exciting cause, and is as often vainly sought 
after; the patient being misled by the well-known sensation 
which follows the enlargement of the small vessels. 

Now, so far from this view of the cause being averse to the 
opinion of its belonging to the class of intermittent and neural- 
gic dis orders, cold so applied is precisely one of the causes 
which produces these also, just as it excites the rheumatism of 
the face; adding a proof, such as it may be thought, respecting 
the true nature of that disease as well as of the ophthalmia in 
question. An average of cases will show that the rheumatic 
ophthalmia is much more common in spring and during east 
winds than at any other time, and the very vulgar themselves 
are indeed convinced of this as to ophthalmia generally: while 
it will I believe be found, that nine cases of ten, or indeed far 



NEURALGIC OPHTHALMIA* 357 

more, if not even all of the ophthalmias thus occurring, are this 
very disease. And I formerly showed, while I have attempted 
to explain the cause, that such east winds, at that season of the 
year, do produce intermittents as well as Neuralgia; so that as 
far as cause is concerned, the whole of these disorders unite un- 
der one general head, instead of being separated by differences 
of cause: while it is still easy to see how the local action of cold 
on the eye or face, might determine the local disease especially; 
the wind thus acting by a double power. 

But if such a local cause may, in spring, especially determine 
the action of Malaria to this part, acting on the superficial nerves 
as it does in the case of a carious tooth or of common Tic, the 
fact really is, that this ophthalmia occurs through the whole sea- 
son which produces intermittents and remittents, if less conspi- 
cuously in the autumn; and also, as I remarked in the last chap- 
ter, that it abounds most in those seasons or years in which 
marsh fever rages most. The recent seasons of highly active 
Malaria in our own country, will establish this fact to any care- 
ful observer. 

But it is completely proved by the geographical bearings of 
this ophthalmia, that Malaria is at least its chief cause, as it is 
that of all the Neuralgias; however ignorant we as yet are of 
the local causes, or otherwise modifying circumstances, which, 
in this case as in so many other diseases arising from that poison, 
determine the particular action. Thus, as I have just remarked 
from Monfalcon, and as I could confirm through many other 
written and living testimonies, it abounds in all the pestiferous 
districts of France: while under the general ignorance of Neu- 
ralgia in all its forms, it is no objection that French physicians 
have not drawn the same conclusion; nor, I might add, Italian 
ones either, nor, in fact, even our own medical persons conver- 
sant in climates of this character, wheresoever situated. 

As further facts of this nature, I may also remark, that this 
ophthalmia, or at least an ophthalmia which, in every case where 
I could procure an accurate report of the symptoms, possesses 
this character, is endemic on all the coasts of the Mediterranean 
where fevers abound; occurring also, very remarkably, at the 
same season, or in the pestilential months of summer and au- 
tumn. Thus, to speak more specifically, it prevails along all 
the marshy or wet coasts of Barbary, during four months; and 
at Tripoli in particular, to such an extent, that few escape it. 
Thus also it is common in Rome, in Naples, where it is falsely 
attributed to the glare of the sun (a circumstance which may. 
however, be an assisting cause) and in Florence, which however 
praised as a climate, cannot be free from Malaria when the Arno 
in summer exposes little but putrid mud and marshes, as well as 
in many other parts of Italy: being also the cause of that ire- 



358 NEURALGIC OPHTHALMIA. 

quent blindness, among the lower orders especially* which can 
scarcely fail to have attracted the attention of travellers. That 
the Lippi of ancient Rome, so often noticed by the classical 
writers, were so from the same disorder and from the same cause, 
is also extremely probable. With respect to Spain, I have the 
most distinct information from the Captain Morillo, inspector of 
health at Alicante, that this ophthalmia is very common on the 
maritime coasts which are subject to fevers, being particularly 
prevalent in Valencia, and at Albatera and Clivillente, and often 
followed by blindness. This testimony is unquestionable; be- 
cause while it is described as attacking the eyes alternately, its 
nature as well as its causes are there mistaken, just as they are 
with us; the latter being generally sought, by the people, in the 
handling of pomegranates. This is just what happens among 
our own vulgar in attributing fevers to autumnal fruits: the sea- 
son of the disease in Spain being September and October, when 
Malaria is most active: while this particular limitation of time, 
as well as of place, the peculiar redness and tumefaction of the 
eyelids, and the incurable (esteemed) nature of the disease, leave 
no doubt whatever that it is the ophthalmia in question. I have 
reason to believe too, from some reports, that this peculiar dis- 
order is found also in the unhealthy tracts of Western Africa: 
but so much confusion has existed among bad observers between 
this and the contagious ophthalmia, that I cannot disentangle 
these reports to my own satisfaction. And let me remark by 
the way, that this latter observation will probably turn out to be 
of considerable importance; as I have seen numerous cases of 
the neuralgic ophthalmia so misnamed in this country, with con- 
sequent maltreatment; and have no doubt that it is a far more 
common error in the climates especially subject to Malaria and 
fevers. If Wardrop remarks that it is frequently attended by 
biliary symptoms, (as occurring, I presume, in autumn chiefly) 
the solution of this fact becomes as obvious, as the fact itself 
confirms a view on which I think I need not longer dwell. 

To proceed to the description of the rheumatic or neuralgic 
ophthalmia. 

There is a peculiarity in the aspect of the inflammation itself, 
far easier to recognise than to describe, and by which alone it is 
generally distinguishable, even at a distance, and on a mere 
glance, to those who have acquired that experience which in 
other cases is called the tactus eruditus. I have sought in vain 
for expressions to say fully what this is; but I believe it to be as 
useless as difficult, since, however accurate they might appear to 
those who already know this inflammation by sight, they would 
not teach others to know it, inasmuch as no visible object can 
be justly described to the previously ignorant; while such a de- 
scription would be useless to those who are already experienced 



NEURALGIC OPHTHALMIA. 359 

in this ophthalmia. The more obvious character, however, is a 
dull, rather than a lively red colour, not unfrequently attended 
by a tinge of yellow; the cause of which is especially visible 
in the sound eye when but one is inflamed, and the source of 
which must now also be obvious, particularly in autumnal cases. 
This inflammation occupies the whole conjunctiva, even to the 
verge of the cornea; and while the redness is rather produced 
by the minutest branches of the arteries than the larger ones, 
the general aspect is almost that of an additional coat of red 
cloth in the severer cases, sometimes attaining a higher level 
than that of the cornea. 

In severity, however, it differs exceedingly from a mere ge- 
neral, and somewhat pale redness of the conjunctiva, to that vi- 
olent inflammation just noticed. Here, it is apt to resemble 
the celebrated contagious and purulent ophthalmia; but it can ne- 
vertheless be distinguished by attending to its progress and to 
the collateral symptoms, while it never, as far as I know it, 
suppurates on the surface, like that disease. This is a part of 
its history, however, on which I must yet speak with some he- 
sitation; as, after many years of observation, whence I con- 
cluded that it never did suppurate, my opinions have been re- 
cently shaken by one or two cases, though I had not the opportu- 
nity that was necessary for satisfying myself as to the real nature 
of the disease in these. Whenever it shall, as a separate dis- 
ease, have received from physicians the further attention which 
it requires, this, and some other circumstances, which I cannot 
now well elucidate, will be better understood , while I shall glad- 
ly avail myself of such information: though it will be necessa- 
ry that this disorder shall be truly discriminated for this purpose, 
lest we return into worse confusion than that which I am at- 
tempting to rectify. 

Such is the general and obvious character; while I shall re- 
serve some rarer particulars for consideration immediately. But 
there are one or two remarkable circumstances respecting it, too 
characteristic to be passed over. It is often unattended by any 
pain in the eye itself; and this seems particularly the fact where 
it is of long standing, and not very severe; though there arc 
cases also in which it is accompanied by as much pain and irri- 
tation as the common, or even the contagious ophthalmia. And 
in such mild chronic cases also, there is, sometimes, not even 
irritability to light; so that, with the exception of the occasional 
feeling of dust or sand, it will often last for many months as a 
mere deformity; the patient, if in low life especially, not apply- 
ing for advice. It is also a peculiarly obstinate species of oph- 
thalmia; continuing unchanged, even for months, in spite of 
every ordinary means of cure, particularly resisting local appli- 
cations, and, as I shall presently show, very common! \ 



360 NEURALGIC OPHTHALMIA. 

vated, and in a very marked manner, by the evacuating system« 
Wardrop has also remarked that there is, at the commence- 
ment, a peculiar sense of dryness in the eye, while that is at 
length followed by abundant lacrymation. If I cannot say that 
I have very decidedly noticed the first of these symptoms, it is 
probably because of a well-known usage, in consequence of 
which, physicians rarely see the commencement of a disease, 
as, with respect to the lower orders, is true of almost every 
member of the profession; but I can bear abundant testimony 
to the lacrymation, while its exceedingly remarkable nature is 
explained, to me at least, on those principles already stated in 
speaking of the neuralgic affections of glands. 

When there is no pain in the ball of the eye, it would seem 
that the conjunctiva alone is affected; while, when irritability 
to light attends, we must suppose that the neighbouring vessels., 
and nerves, within the eye are in that state, be it from sympa- 
thy or extension, which so often occurs in the rheumatism of 
the face and in common Neuralgia, where, added to the decided 
inflammation and pain, there is an excitement, a tenderness, or 
an irritability in the adjoining parts. It is not necessary that 
the eyelids should be affected, or that the inflammation of the 
conjunctiva of the eye should extend over that of the eyelid; 
though this happens in the severer cases, and, as it would seem, 
rather in the acute than the chronic ones. It is a fortunate cir- 
cumstance, that this inflammation is so much and so often re- 
sisted by the transparent cornea, as is the fact also in some other 
ophthalmias; but abundant instances of this do nevertheless oc- 
cur rigidly speaking, and in the severer cases, the cornea be- 
comes dull; and if this opacity proceeds, it at length forms a 
cloud or a spot which diffuses itself over the whole eye, while 
it is more condensed in the centre. Fortunately, even when 
very considerable, this commonly disappears, under proper treat- 
ment of the general disease, and even within a day or two; 
while I have seen it return many times, under different relapses 
and in successive seasons, without any more permanent effects. 
In such cases, also, it will sometimes be found, by means of a 
lens, that there is an ulterior disorder of the cornea, resembling 
very superficial ulceration; equally disappearing, and without 
bad consequences, with the general inflammation. Far more 
rarely does it affect the iris; but cases even happen, as I shall 
soon show, where that membrane alone is the seat of the disease; 
the neuralgic affection producing here a rheumatism of the iris; 
to adopt the common phraseology. 

Supposing that the inflammation, thus complete or severe, has 
not been cured, or, as is the fact, has been neglected or mal- 
treated, the ulterior unfortunate terminations may be as follows: 
In the acuter cases, the ulceration of the cornea may increase so 



NEURALGIC OPHTHALMIA, 3M 

as to perforate it, in which case the eye collapses, commonly for 
life; though this is sometimes healed, with a partial or perhaps 
entire restoration of the figure at least of the eye-hall. In still 
worse cases, matter forms within the globe of the eye, and it 
bursts; and I much suspect that the cases of single eyes thus 
lost, which are not uncommon, might all be traced to this par- 
ticular disease. In what may be considered acute cases also, if 
less severe, a pustule, or minute abscess, is sometimes formed 
in the cornea, inducing, of course, blindness; and further, in 
these, this portion of the eye will become permanently opake, 
while opacities are the frequent terminations of the chronic 
eases, misunderstood and maltreated. I shall be much mistaken 
if the very great majority of cases of opacity in one eye, as 
well as not a few where both are thus affected, have not arisen 
from this, the most common assuredly, of all the varieties of 
ophthalmia, though so little suspected, or rather so nearly un- 
known: since the essay of Wardrop, correct in the practice 
which it points out, seems to have produced little effect on the 
mass of practitioners; while if it had, from not distinguishing 
the chronic forms, it leaves those persons still in the dark as to 
the predominant cases of this ophthalmia. 

The neuralgic ophthalmia sometimes attacks suddenly, and 
appears within a few hours, in all the perfection which it is about 
to preserve; but it is often also preceded by an intermittent or 
remittent febrile state, sometimes so slight as to be overlooked, 
not only before the disease, but during its continuance. And, 
as far as I have observed, some symptoms of this are always 
present; though it is very seldom that we can ascertain that it 
has preceded, because the patient has paid no attention to a dis- 
order so slight. On other occasions, it is the sequel of a pre- 
vious distinct neuralgic pain, which sometimes lasts even a long 
time before the inflammation comes on. That neuralgic pain is 
also, as the precursor of this ophthalmia, most commonly seated 
in the face, and very generally in the eyebrow or the temple, 
though sometimes even in the lower jaw; being, in many cases, 
a common hemicrania, or a periodical headach of some kind, or 
a clavus; though I have seen cases also, where it has been situ- 
ated in even more remote parts, such as the arm. Further, this 
previous disease will occur as a rheumatism, in perhaps any 
part, or even as general or diffused rheumatism: the ophthalmia 
following it, perhaps being continued from it, or else appearing 
as a replacing disease. All these circumstances mark distinctly 
its connexion with intermittent and with Neuralgia in general: 
and when it replaces another rheumatism or another Neuralgia, 
this is precisely what occurs so often in the anomalous intermit- 
tents as they were formerly described. I shall shortly relate 
one or two cases which, illustrate some of these rarer facts. 



362 NEURALGIC OPHTHALMlAr 

But T must remark, before proceeding further, what indeed the 
reader might now almost have inferred for himself, that the cha- 
racters of this ophthalmia will be very mainly regulated by the 
fact of its being an acute or a chronic disease. In either occur- 
rence it is analogous to the remittents and intermittents of the 
same characters, as also to the several anomalous inflammatory va- 
rieties of those disorders with which, but for the causes already 
stated, it should in fact have been ranked. And in either, the 
proper intermittent fever may be very visible, or may be ob- 
scured by the local affection, or may really be obscure, or may 
be neglected by the physician, or mistaken for the symptomatic 
fever of inflammation: and in all these particulars also, it resem- 
bles the anomalous and simulating marsh fevers formerly de- 
scribed; just as, on the other hand, it resembles the pure Neural- 
gias, in all of them. The distinction between acute and chronic is 
therefore the primary and important one: while it appears to 
me that the latter has been especially neglected, and, as far as I 
can see, not even ranked under the rheumatic Ophthalmia by 
those who have used this term in describing the acute one: that 
neglect being also the source of the more numerous evils pro- 
duced by this disorder. 

Supposing the disease to be established, under any of these 
modes of attack, the following circumstances will, in a greater 
or less degree, be found to attend it, by a careful observer: 
while I need scarcely remark again, that they are perpetually 
overlooked by the mass of practitioners, attentive only to an 
obvious symptom, in the usual manner, and, very generally, ut- 
terly ignorant of the existence of such a disease, or at least of 
its real nature and theory; or, if now partially informed of it 
through Wardrop's essay, perhaps refusing to believe on the 
testimony of others, what they have not observed themselves^ 
because adding prejudice, and sometimes pride, to want of dis° 
crimination. 

A watchful physician will rarely fail to perceive that physi- 
ognomical mark of a cold stage at some period of the day, 
which 1 have so often pointed out; as the fever of this disorder 
is generally, but not invariably a quotidian; while in many 
cases, that stage, and even a hot fit also, are distinctly marked. 
This is true even of the slightest varieties, and of the most 
chronic or most habitual and repeated ones: while in the severer 
acute disease, the fever is strongly marked as a remitting, or 
even as a continuous one; as continuous at least as in simple re- 
mittent: though, under types more distant than quotidian, I 
have met few of a severe character; those of a tertian form ? 
which have occurred to me having b^en most commonly mild^ 
or else elm nic cases. 

Such a febrile state is often ? as usual; paroxysmal; while the 



NEURALGIC OPHTHALMIA. 363 

inflammation is permanent; but this is no cause for surprise, as 
the same happens in the rheumatism of the face, in that of the 
intercostal muscles, and in other analogous affections, and also 
not (infrequently in the purer Neuralgia?, as in sciatica. Sup- 
posing this febrile state to be present or not, or to be more or 
less distinct, there is frequently a separate neuralgic pain accom- 
panying the inflammation, throughout the disease, or, occasion- 
ally, for some days only; being the hemicrania, or the pain in 
the temple, or in the eyebrow, which I formerly noticed as 
sometimes preceding the attack; and being sometimes an ex- 
tremely severe Neuralgia. This is the symptom which forms 
that criterion for the disease which ought never to be mistaken, 
though in reality rarely attended to; and it is so marked and so 
discriminating, that, to pass it without notice, or, when pre- 
sent, to treat the disease as common ophthalmia, is unpardona- 
ble in even the most mechanical practitioner. I might add to 
these several collateral symptoms, all of them proving the neu- 
ralgic and intermittent nature of this ophthalmia, those other 
numerous disturbances of the general health which so often oc- 
cur in intermittents and Neuralgias; but this would be merely to 
repeat that which jean scarcely yet be out of the reader's memo- 
ry. Where bilious affections accompany it, the explanation al- 
ready suggested becomes still more obvious, as this view equally 
explains the utility of Emetics. 

In this disorder, it may happen that both eyes are affected? 
but as far as my own experience goes, the affection, in the great- 
er number of cases, is in one eye only, or at least, only in one 
at one time. This, in itself, is a highly discriminating charac- 
ter; and I much question if there is any other of the ophthal- 
mias which determinedly affects but one eye, unless by a mere 
casualty. It is this neuralgic ophthalmia which ought at least al- 
ways to be expected and inquired for, wherever one eye alone 
is found to be affected. And if pain should be present, it will 
generally be found that it is in the neighbourhood of the dis- 
eased eye; while it will often be very marked in such a spot, 
even when that organ itself is free from pain. 

A further character, peculiar, or I believe, exclusive, to the 
neuralgic ophthalmia, is the transference of the inflammation. 
I call it transference, from its obvious nature, as well as in con- 
formity to the common notion of metastasis in diseases, but I 
consider it to be, philosophically, a paroxysmatic state of a truly 
periodical variety of this disorder under a peculiar type. Both 
the eyes must, in this case, be considered to be under a morbid 
state of susceptibility, or of dormant disease, if I may use such 
a phrase, similar to that which exists in the nerve in Neuralgia 
when not actually producing pain. And the disorder itself finds 
its analogy in the double tertian, supposing the disease to alter- 



884 NEUSALGIC OPHTHALMIA. 

nate daily, as it is not unfrequently found to do: while otbei 
parallels are not wanting, should the transference be less regular, 
or should one eye, long affected, become well, while the other 
inflames; since similar occurrences are common in all the ano- 
malous or local intermittents; as for example, when the rheu- 
matism of an arm is exchanged for palpitation, or a toothach for 
common intermittent: cases which, together with other analo- 
gous ones, I pointed out formerly. 

Where this remarkable symptom occurs, the original inflam- 
mation, however previously severe, sometimes disappears entire- 
ly, even within a few hours, so that its former existence could 
not even be suspected; while, in a corresponding manner, the 
new one attains its utmost violence in a time as short, often to 
disappear again in the same mysterious manner. It is surprising 
that a fact so extraordinary as this should not have attracted sus- 
picion long ago; since nothing analogous to it occurs to other 
parts, if we except gout, and some very rare cases indeed of 
metastatic diseases, of which even some are probably more in- 
timately connected with intermittent than has ever yet been 
suspected. It is more surprising that where the quotidian or 
tertian type has attended these changes, the true nature of the 
disease should not have been suspected: but perhaps we must be 
surprised at nothing, when the whole of these disorders have so 
perseveringly been misapprehended, even when less encumbered 
and obscured by a local and misleading symptom. 

Such is a sufficient description of this disorder in its more ge- 
neral forms; nor, with this, does there seem to me any difficul- 
ty in recognising it wherever it occurs. The mention of one 
or two other circumstances will complete its history, as far as it 
seems necessary to detail that. 

Like other neuralgias and intermittents, it may be limited to 
one attack, or, having occurred, more than once in the same pa- 
tient, it may put on a tendency to relapse, and thus appear re- 
peatedly. And like all these diseases, it often disappears spon- 
taneously; while the remedies gain a credit that does not belong 
to them, as the common mode of treatment is very generally 
either nugatory or mischievous. I must however remark, that 
the terminatian of the ophthalmia is not always that of the 
whole disease as I view it: since a general intermittent, if of a 
slight or obscure character, frequently remains: a fact equally 
common in the toothach and the rheumatism in the face, when 
at all periodical or attended by a marked intermittent; while 
this, I presume, must chiefly be expected in cases where the in- 
termittent is of a chronic character, or when the patient has 
suffered from other forms of that disease. 

As to the theory of neuralgic ophthalmia, if it is not very 
evident^ it is at least as intelligible as that of any other form of 



NEURALGIC OPHTHALMIA. 365 

neuralgic inflammation. Of the true, the ultimate theory, of 
any inflammation, we know absolutely nothing: since, after all 
that has been written on this subject, we have but so many 
words; one term substituted for another. If all that we can 
know as yet of the cause of neuralgic inflammation is no better, 
it is at least not worse; while we are in no want of analogies, 01 
the difficulty, such as it is, is countenanced by parallel difficulties. 
I formerly showed that the intermittent hemicrania sometimes 
affected one eye; so as to produce lacrymation, and also a daily 
habitual inflammatory state of the eye. It is but to suppose this 
augmented and rendered more permanent, and we have the oph- 
thalmia in question; it is but to suppose the intermittent over- 
looked, as it most generally is in this state, and the ophthalmia 
will appear the sole disease, as every Neuralgia does to those 
who are equally inattentive. And that this is possible, is proved 
by the rheumatic or neuralgic inflammation of the face or jaws. 
The disease here may be mere pain, it may be pain with tem- 
porary or slender inflammation, or it may become permanent 
inflammation; and moreover, it may also terminate in an abscess j 
a fact, further, which occurs, if rarely, in the eye also. The 
analogy is perfect, as the cause is the same; while we can find re- 
moter, though not less instructive analogies, in the local and pe* 
riodical rheumatisms of various parts, attending intermittent 
where there is equally inflammation; similarly variable in seve- 
rity and duration, similarly periodical, and similarly transferri- 
ble, or interchangeable with other disorders of the same generic 
nature, or with those which attend anomalous intermittent. 

I might now proceed to the treatment of a disease which I 
have probably described at sufficient length; but it will pre- 
viously perhaps be useful to describe two or three individual 
cases of the most remarkable nature, since I observe that such 
narratives often excite an attention and produce an effect rarely 
attained through any general description. 

In the first case that I shall notice, which was not under my 
own care, but under that of a medical friend particularly inte- 
rested in the result, the original disorder or attack was a perio- 
dical and daily rheumatism in the neck, remarkably well de- 
fined. After this had lasted a week, there occurred suddenly a 
pain in the eye, with inflammation of a very violent character. 
I entertain no doubt that the intermittent form remained, cither 
in the febrile symptoms or in the pain about the eye; the vio- 
lence and acuteness of this being a very discriminating mark, 
as it does not happen in any other ophthalmia. But as this phy- 
sician had never considered the rheumatism in question as a dis- 
order belonging to intermittent or neuralgia, he had paid no at- 
tention to the symptoms, and was therefore unable to describe 
the case more minutely. Far less had he ever considered 



366 NEURALGIC OPHTHALMIA." 

ophthalmia to be a disease of this nature; and the patient ivas 
therefore treated in the usual manner, with the unfortunate ter- 
mination in blindness, from the formation of a pustule in the 
cornea. I have given this case as I received it from the physi- 
cian himself, so that others may judge; while the suddenness 
and violence of the attack of inflammation, the accompanying 
severe pain, and the previous periodical rheumatism, leave no 
doubt in my own mind respecting the nature of the disease. 

If the formation of pustules or opacities has been thought rare 
in the rheumatic ophthalmia, by those who have known this 
disease, and distinguished it by this term, it is a question on 
which I must add a few words; having been unwilling to enter 
into an argumentative discussion of this point in the general de- 
scription, on account of the difficulty which I have experienced 
in convincing those with whom I have argued this subjec f , that 
opacities could be the produce of this variety of inflammation. 
If this opinion shall be confirmed, it will evince more strongly 
than ever, the necessity there is for reforming the history of 
ophthalmia, and for establishing that theory of this variety 
which I believe to be the true one. It is a most important ques- 
tion as relates to the practice: since, at present, the want of suc- 
cess, or rather the'consequent evils, are generally the direct pro- 
duce of maltreatment, or at least, they are very often produced 
by this, if often also by mere neglect or ignorance of that which 
is the right method. 

It is common, as I remarked already, to find persons who 
have suffered the opacity of one cornea; and though it is often 
difficult or impossible to obtain the history of past cases, I have 
found reason to believe, in the few where I have been able to 
get information, that the original inflammation had often been 
of this nature. It is much more easy and safe to form the same 
conclusion in another class of cases by no means uncommon; 
nor have I ever been fairly put into possession of one of these, 
where I have not been able to decide that the opacities in ques- 
tion had been the produce of this very variety of ophthalmia; 
while the other conclusion was no less obvious, viz. that a mis- 
taken view and a wrong practice had most probably been the 
causes of the evil. The cases to which I here allude, are those 
where we find, that, through many years, sometimes through a 
long portion of life, an inflammation, more frequently of one 
eye than both, will return at different periods, often without ap- 
parent causes; while, from some one of these, there has been 
produced an opacity more or less extensive, to which other and 
successive ones form additions; the termination in severe cases, 
being at length in absolute blindness. If, at the commencement 
of my investigations into this disease, I was both unwilling to 
believe this, and afraid of adopting the practice which I have 



NEURALGIC OPHTHALMIA. 367 

suggested, a further experience has rendered my mind at ease 
on this subject: nor, always supposing that a right decision has 
been made as to the nature of the inflammation, can I doubt of 
the correctness of the practice, when I have found that yield, 
and the incipient opacity also, whether the first or an additional 
one, disappear in a few days under it, and when, in the same 
patient, every previous attack had lasted for weeks or months, 
while, in some instances, each severe relapse had extended the 
opake spot. 

Passing over the question of mere opacity, it might be said, 
on theoretical views, that suppuration should not happen in such 
cases; but while we know so little of any inflammation, we can- 
not say that neuralgic inflammation, and in a membrane, ought 
not to produce abscess, inasmuch as rheumatism does not; while 
this is a doubt which I examined formerly: and as this does ac- 
tually occur in the membranous and equally neuralgic inflam- 
mation of the gums, as I then showed, there is a perfect analo- 
gy to justify the possibility of its occurrence in the eye. Fur- 
ther than that, I shall lay no stress on this part of the preceding 
case; leaving it to future observation, whenever this disease shall 
be admitted and understood as universally as it ought to be. 

In proof that this disorder is not so admitted and understood, 
let me now say that the physician in question was not one of 
the ordinary mass of routine practitioners, but the most learned 
and the most attentive of all my personal acquaintances, a man 
to be admired and esteemed most by those who knew his talents 
best. I note this, because it argues strongly for the necessity 
of a new investigation of this disease, when the want of a pre- 
vious mark on it could so mislead such a man, and in acasealso* 
where he had the deepest possible interest. And that he was 
so misled, generally, will be further proved by the next case I 
shall relate, which I have however selected on account of its very 
definite and remarkable character; since even in this, marked 
as it was, and which I attended with him, I could not convince 
him of the existence of such a disease as I have been describing? 
or that this was an illustrative case of it. 

In this instance, and where the personal interest was as great, 
the patient was suddenly attacked in the evening with an in- 
flammation of one eye, which ceased by the following morning. 
On the next evening, there was no inflammation; but it returned 
on the alternate one, and in the other eye, terminating similarly 
on the following morning. As I chanced to reside in the house, 
I could perceive and point out the tertian cold stage; this being 
evidently a tertian intermittent, or rather, that disorder doubled, 
(not double tertian) inasmuch as the succeeding fits were differ- 
ent. Nothing was done; as it was wished to watch the natural 
progress of the disorder, which, after lasting thus about ten days, 



368 NEURALGIC OPHTHALMIA, 

or displaying six different alternations of this nature, became a 
decided double tertian; the inflammation returning every even- 
ing in the alternate eyes, to terminate in the morning. And in 
this instance, the neuralgic intermittent pain occurred in each 
eyebrow alternately, accompanying the inflammation; so as to 
produce a case as strongly marked as is easily conceived. I 
shall only add that it was afterwards cured by bark, but that I 
did not even then succeed in producing a free assent to opinions 
which, probably, I might even now have kept to myself, for all 
the impression they are likely to make for these twenty years to 
come; when those who have been most active in opposition, will 
be among the first to recollect that all this was long ago their 
own opinions. 

In the last case which I shall notice, the patient had been for 
some time afflicted with a general or diffused periodical rheuma- 
tism, which, at length was followed by inflammation of both 
eyes, the original disease continuing. I did not see this case 
till long after its commencement, and when the cure was per- 
haps hopeless; at which time both the pupils were so contracted, 
that a pin could with difficulty have passed through one, the 
other being absolutely closed. By the patient's account, he had 
been seized with occasional fits of blindness during the progress 
of the disease, arising doubtless from the contraction of the 
pupil, while I have as little doubt that the Iris was affected by 
the neuralgic inflammation. I could not obtain a more minute 
account of the case, as he was a man in low life, and had no 
medical attendant; but enough remained to prove that the judg- 
ment I had formed was correct. For, at this time, though one 
eye seemed hopelessly obstructed, the other was occasionally of 
use; while the patient observed, and without inquiry, or leading 
question, that whenever the general fits of rheumatism in the 
limbs came on, the eye became blind, from the closing of the 
pupil, recovering again when those ceased. I need only add, 
that as the disease had at this time lasted many years, the fits 
were no longer as regular as they had originally been, as hap- 
pens in all chronic intermittent disorders; and as the contraction 
of the pupil accompanied them then accurately, it is probable 
this had done so from the commencement, though the exact par- 
ticulars had been forgotten. I must presume that the disorder 
which I have thus described, as far as relates to the contraction 
of the pupil, would find a sort of place under the myosise and 
metosiad of systematic writers; and while I have sometimes rea- 
son to suspect the same cause in some of the recorded cases, I 
find little satisfaction in reading the confused descriptions of the 
symptoms, and feel little confidence in deciding on their identi- 
ty, however I may suspect that the greater number of them be=. 
long to the disease in question, 



NEURALGIC OPHTHALMIA. 369 

Let those who have more opportunities than myself of see- 
ing this disorder of the Iris, examine such cases on this view, 
and we shall then know how far this theory applies to them; 
since, as I have just observed, we can judge little or nothing 
from former recorded cases, inasmuch as they have been report- 
ed without the necessary attention to the marking symptoms. 
But if it is agreed that the inflammation of the iris is of a " rheu- 
matic" character, it is probable that the present view is the cor- 
rect one, and that all the cases belong to the neuralgic and pe- 
riodical diseases under review. And that, at least, it is fre- 
quently so, I can confirm from many cases, in which this dis- 
ease of the iris has either preceded, or followed, or run parallel 
with the common neuralgic inflammation of the conjunctiva al- 
ready described, and in which the true nature of that was am- 
ply proved by the accompanying symptoms. One, very parti- 
cularly marked, ought perhaps to be mentioned, because, in this, 
while the first symptom of all was simple Neuralgia of the face, 
with a marked intermittent paroxysm, it was succeeded, first, 
by the contraction of the pupil in the nearest eye, after some 
time followed by general inflammation of the conjunctiva, and 
lastly by a universal periodical rheumatism: all of these being- 
connected by one general disease, and ail illustrated by the va- 
rious facts as to anomalous intermittent and Neuralgia already 
described. 

I have yet two suggestions to offer, which I was unwilling to 
introduce into that more pure history of this disease which I 
have deduced from unexceptionable and sufficiently numerous 
cases. I have had reason to suspect, though it is scarcely more 
than suspicion, that the neuralgic inflammation was capable of 
reaching or attacking the crystalline lens, as well as the iris, or 
the other humours, and thus of producing cataract. If indeed 
Sauvages makes this remark on his " migraine des yeux," it is 
of no value, since the term he applies to the cataract thus in- 
sinuated, does not. appear to mean an opacity of the lens. Un- 
fortunately for my decision in this case, the practice in all the 
disorders of the eye has been, in London at least, so entirely 
taken out of the hands of physicians, as also far too much from 
those of surgeons in general practice, that I have no opportuni- 
ties of confirming what the examination of two or three cases 
had led me to suspect; a fact which, simple as it may appear 3 
tends to illustrate the evils which arise to physic as a science, 
from the separation to which I have here alluded. In the pre- 
sent state of doubt therefore, I must leave this suggestion to the 
inquiries of the oculists; though with little hope of light, ex- 
cept from the very few, who, fortunately for medical science, 
have contrived to retain a share of this department, as sui 

i: 



370 NEURALGIC OPHTHALMIA. 

and physicians engaged in general practice also, in their own 
hands. 

And while to promote the Science has here been my sole ob- 
ject, for the sake of those who, whether as physicians or patients, 
may profit by the Art, I may be allowed to remark that this is 
but one case out of hundreds, in which a public, at once igno- 
rant and over-wise, suffers for its own folly: for ever guided by 
fashion, or considering physic as a mechanical art, best adminis- 
tered, as chairs and tables are made, under division: while from 
the usual illiberally of feeling which, in-a commercial country, 
can see no motive of action but gain, the physician or surgeon 
who argues against the system is accused of being himself swayed 
by motives of self-interest. » So little is it considered, that even 
in this country, but far more in the other parts of Europe, there 
are thousands who pursue science as well as literature for the 
sake of science and literature alone, even to the sacrifice of pri- 
vate interest; as there are many more by whom gain is felt as a 
necessity, not a primary motive, and in whom that necessity is 
still made secondary to the cultivation of knowledge Thus 
also, in this very case, does the multitude which passes this cen- 
sure, forget thnt splendid effort>of generosity on the part of the 
medical profession, the introduction of vaccination, and the per- 
severance with which it pursued this object even against public 
opinion: an instance of the sacrifice of private advantages to the 
good of mankind, of which no other profession has ever, or in 
any age, furnished an example: and a fact which, in particular, 
presents also, the most absolute contrast to what has ever been 
the conduct of one of these, The Law. 

To return. The other suggestion relates to Amaurosis; and 
it rests similarly on some partial observations, in the first in- 
stance, but is better supported, both by analogy and an exami- 
nation of recorded histories. The general analagy of all the 
Neuralgias tends to show, in the first place, that such is not an 
improbable event as the consequence of this disease, whether 
flowing immediately from improper treatment, or from their ge- 
neral tendency towards palsy. And if it is easy to understand 
how a paralysis of the retina might follow in any case where, in 
this ophthalmia, the neighbouring nerves had been afiected, it is 
particularly obvious how it might be the termination of the sim- 
ple Neuralgia of the optic nerve formerly described. 

Again, to derive another analogy from intermittent fever, 
since the value of those has often been here demonstrated, I for- 
merly noticed from authors, two cases of Amaurosis connected 
with that disorder; suggesting then a possibility respecting its 
cause, which 1 must nevertheless, in some measure repeat here. 
They are, in any view, valuable as to the history of this hither- 



NEURALGIC OPHTHALMIA. 371 

to almost incurable, and much neglected disease: and though to 
be rai ked with the primary palsies arising from Malaria or in- 
termittent, they will at least confirm the possibility of its also 
arising more indirectly, from the cause which I am here contem- 
plating; since this is, again, one of those involved cases of local 
and general action which are so difficult to separate, and which 
never cross me without causing me to regret that I have been 
here obliged to separate them. 

I may here add that Plater also describes a case of amaurosis 
produced by intermittent; nor, whatever illustration it may af- 
ford, whether it should be irrelevant or not, can 1 avoid here 
pointing out a very remarkable cause of that disorder, which 
can scarcely be absolutely unanalogical, This is the amaurosis 
once so common among the nightmen of Paris, but which has 
now, I believe, disappeared under better regulations: the blind- 
ness being almost instantaneously produced by the impression 
of the poisonous gas in question. Be its value what it may in 
this argument, it at least illustrates the operation of Malaria in 
the production of palsy. 

And while I remind the reader of this leading analogy, let 
me also remark, that while the attack of amaurosis is sometimes 
sudden, the affection is, in this, not less singular, that there is 
often no disorder in the head or the intellectual faculties; no- 
thing indicating disease of the brain, but the whole derangement 
appearing to be one of the retina or the nerve alone. And when 
I have seen the amaurosis of one eye produced in a day, appa- 
rently indeed within an hour or two, during exposure to a cold 
or moist wind, in a young and healthy man, that exposure also 
having been in marshy ground, in shooting snipes, and without 
any other apparent derangement of health, I can as easily un- 
derstand why the Neuralgia should attack the optic nerve in this 
form as it does in that of pain, from the same cause or how, if 
we prefer the other view, the disease should have been a par- 
tial or localized intermittent thus produced. 

Such are the chief arguments and illustrations as to the possi- 
bility of the dependence of amaurosis on the neuralgic inflam- 
mation of the eye or on the Neuralgia of the neighbouring parts 
in any form, since it would be superfluous to make a separate di- 
vision for this disorder, and it really is unnecessary to separate 
the cases. And I am further confirmed in this opinion by the 
remarks of some authors, and especially of Schenkius, on an 
amaurosis produced, as he says, by spasms of the moving mus- 
cles of the eye, acting so as io compress the optic nerve. Thus 
at least would I analyse a case in which his solution certainly 
deserves little praise by an anatomist. The accompanying and 
previous symptom of note, was a violent headach, and I doubt 
not, a Neuralgia: and if I conjecture that the same explanation 



372 NEURALGIC OPHTHALMIA. 

applies to some cases of amaurosis from violent pains in the head, 
related by Morgagni, Vieussens, and others, I am weary of at- 
tempting to extract from confused narratives of disorders falsely 
viewed and interpreted, such apparent truth as those who are 
equally ignorant or misled will be delighted to reject whenever 
that is possible. 

Let me yet, however, add, and while this sheet is in the 
press, that since these remarks were written, I have met with 
two marked cases of amaurosis of one eye, produced very point- 
edly, and within a few weeks, by a Neuralgia occupying the 
external part of the orbit: the gradual paralysis of the nerve, 
and the total absence of all other affection of the head, or of the 
corresponding eye, offering evidence as clear as could be desired, 
of the real source of the disease, and of the truth of the above 
conjectures. 

And if, throughout this essay, I have often been obliged to 
produce conjectural testimony, from the inattention of physi- 
cians to the subjects and views of which it treats, I may here 
introduce a fact which appears to me to bear on this question, 
and on the original one, viz. the power in this respect, of the 
inflammatory diseases; but of the value of which I shall suffer 
others to judge. This fact is, that in the Mediterranean, and in 
the same districts where that ophthalmia which I suppose to be 
the disorder under review is common nyctalopia, as it is there 
improperly called, or in reality, the loss of vision after sunset, 
is a very common affection: while I need not remark that this 
is, in fact, a modified amaurosis, or a partially, or moderately 
paralytic affection of the retina or nerve. To trace any indi- 
vidual cases of this nature to the previous ophthalmia, would 
complete a piece of evidence which must as yet remain imper- 
fect. I need scarcely now suggest, in concluding these remarks, 
that should this view of amaurosis prove well founded, even 
but for a proportion of cases of that wretched disorder, it will 
lead to valuable revolutions in the present practice, as well in 
regard to the remedies for good as for evil; while to insist upon 
that point now, would be utterly superfluous. 

I ought now to proceed to the treatment of this disease, 
which it might be anticipated, would be, on the present views, 
that of Neuralgia in general. But, as in the case of toothach, 
it is absolutely necessary to examine the former practice, not 
merely because it throws light on the very nature of the disor- 
der, inasmuch as the system followed produces exactly the same 
evil effects which it does in all intermittents and Neuralgias, but 
because of those very evils themselves, which are often extreme- 
ly serious, both as positively injurious proceedings, and as di- 
verting the attention from the real remedies. These again, in 
examining I must criticize: nor. without that, could I possibly 



NEURALGIC OPHTHALMIA. 373 

treat of the cure of this disorder. The Isedentia as well as the 
juvcuitia, to use medical phraseology, always demand attention 
from the physician; and if the Isedentia here are the produce 
of physic itself, it cannot be my fault if physic suffers from the 
examination, and physicians also, as far as they administer what 
is hurtful. Both here and in treating of the toothach, I would 
more gladly have avoided such criticism, than in any other case 
that has preceded; because as both diseases have by degrees al- 
most fallen entirely into the hands of separate classes of practi- 
tioners, not physicians, and further, too often, not even surgeons, 
in the proper, practical sense of that word, such remarks will 
appear the more offensive, involving, as they must appear to 
do, distinct and small classes of men, than if they had affected 
the entire multitude of practitioners in all classes. But this I 
could not avoid with justice to the subject, and must even sub- 
mit to the chance of being wilfully misapprehended, and the 
accusation of having written with a sort of general personality 
which has not once entered my thoughts. 

Yet I cannot concede that physic has gained by that some- 
what modern fashion which has separated the profession of the 
oculist from those of the physician and surgeon; making the 
diseases of the eye a trade rather than a branch of the general 
science, and reducing it, very nearly, like that of the dentist, to 
a mechanical ?,rt. That physic, altogether, as a science, and 
even, in many points, as the art of healing, has been injured, 
or at least retarded, by that greater separation which has been 
established in it, will scarcely be doubted by any philosopher; 
however expedient, or rather convenient, that separation may, 
practically, be to practitioners themselves. In the study of that 
chaos, English law, from unavoidable circumstances connected 
with its overwhelming multiplicity, superfluity, and confusion, 
the effect of this separation is such, that a lawyer, in the proper 
sense of the term, scarcely exists, while if we look through the 
general mass, this art and study, science it cannot surely be 
called, is so divided, that while each has his department, he 
scarcely knows what is the pursuit or knowledge of his neigh- 
bour; so nearly does this also approach to a mechanical empiri- 
cism, just as it is almost a pure trade. 

Thus must we deprecate that ulterior subdivision of practi- 
tioners in physic, to which there is at least a strong tendency, 
when we daily hear how much one man is expert in one disease, 
and another in something else; since the event would be to re- 
duce every thing to a pure empiricism. Nor can 1 doubt, 
among other points, that while this separation has had a most 
injurious effect as to the science, in every division of disease 
where it has yet occurred, it has been perhaps particularly inju- 
rious in the case of Mania; though I know very well on what 



374 NEURALGIC OPHTHALMIA. 

grounds this opinion will be disputed, while I could not provide 
an answer for these arguments without infringing on a subject 
which is not now before me. 

And s far as the practice in physic is already thus separated? 
it is actually such an empirical art, or in imminent danger of be- 
coming so, in every hand by which it is thus partially exer- 
cised. If the oculist had no other duty than to operate, we 
could admit that he would be a better, because a more practised 
mechanic than the general surgeon from whom he has separated; 
though even this may be questioned, where there is really no- 
thing so especially difficult in his most delicate operations. But 
it is not easy to comprehend how any practice, and theory, of 
physic, can be duly considered by him who has cut off that one 
branch from the whole body of the science; while it is most 
certain, in fact, that it never is so understood. In the particu- 
lar case under review, I have shown that ophthalmia is often, not 
an independent, or a local disease, or a disorder of itself, but a 
variety in a series of the most obscure constitutional diseases 
which exist; requiring great delicacy of discrimination, as well 
as universality of medical knowledge and of experience: of 
which it is an ample proof, that it has, like all its congeners, so 
long been a subject of misapprehension. Were it even other- 
wise, the constant habit of contemplating one single subject, and 
that subject as a trade and a branch of mechanism, abstracted 
from all its connexions, cramps the judgment and obscures the 
talent for observation, even where these exist or have existed, 
and even in persons of a real education; while it is easy to con- 
jecture what the consequences must be, where such a depart- 
ment is occupied as a mere art, by those who have not laid the 
solid foundation of science by means of universal physic and 
surgery. But I need not extend remarks which, nevertheless, 
I could not avoid, connected as they are with the knowledge of 
diseases treated chiefly by oculists; persons also, in whom it 
will chiefly lie. should the present separation continue fashiona- 
ble, to administer the cuse, after having convinced themselves, 
if indeed that shall ever happen, that they have been wrong. 
But it would be highly unjust to blame this department of prac- 
tice solely, for the past mistakes, since those pervade all practi- 
tioners, as I have shown; though it is to be expected that they 
who are conversant with all these diseases, as physicians, will 
more easily adopt just views than those who have no such op- 
portunities, and who are long likely to pursue the routine which 
has been habitual to them. 

To proceed to the examination of the usual, and as I consider 
it erroneous and pernicious practice. As long as this particular 
inflammation was confounded, and as long as it shall continue to 
be confounded with common ophthalmia, or with true, simple 



NEURALGIC OPHTHALMIA. 375 

inflammation, (if by these terms I may distinguish what all un- 
derstand and no one can explain,) the practice has been, and 
will be, that which is applicable to such inflammations in gene- 
ral, namely, evacuation, and principally blood-letting, both ge- 
neral and local, together with purgatives, and further, blisters; 
a routine practice, in short, which all can conduct without exa- 
mination or reflection. I need scarcely add to this, what is 
equally familiar, astringents and stimulants of various kinds, in 
the form of topical applications; applications that have been 
multiplied in the shape of lotions, solutions, or ointments, by 
those, that large mass, who expect to find in variety and multi- 
plicity of substances and medicines, what never yet was found, 
and who forget that the useful, the only real knowledge, is 
knowledge of diseases, not of Pharmacopeias. That professed 
oculists in particular should especially abound in such expedi- 
ents, was to be expected; since, to the want of general princi- 
ples, principles which teach how to classify and rescind reme- 
dies, instead of multiplying them, as if each metal or each sti- 
mulant possessed some specific virtue of its own, is naturally 
added a kind of necessity, as well as a desire, to appear more 
refined and more mysterious than physicians and surgeons in 
general. 

The fundamental error then, here, lies in not distinguishing 
the particular rheumatic or neuralgic inflammation from others., 
in looking solely at the local disease, and even, at that, careless- 
ly; and in not perceiving the constitutional affection which be- 
longs to every Neuralgia, and which, with varying local tenden- 
cies, produces all the disorders enumerated in this essay. 

Yet I do not say that the rheumatic inflammation of the eye 
has always been thus overlooked, having indeed already pointed 
out a marked exception: since, although it has been mistaken 
for common ophthalmia, perhaps in ninety-nine cases of a hun- 
dred, and is still daily so mistaken; there have been practition- 
ers, among whom I have already named the most discerning, 
who have seen that it was a different disorder, though still not 
perceiving its true affinities; and who have consequently at- 
tempted to vary the treatment, and successfully. Yet for want 
of a correct theory, that treatment has not been established on 
those general principles which would have given it an authority 
sufficient to produce the requisite effects, by generating an effi- 
cacious conviction; while it is chiefly also perhaps for want of 
this correct theory, that the chronic or milder cases, which form 
the vast majority and produce the greatest arithmetical quantity 
of evil, are still confounded with common ophthalmia, and con- 
sequently, maltreated. And if even the utility of bark has 
been shown, that substance has been adopied by those who have 
followed what was taught, rather empirically, than from any 



376 NEURALGIC OPHTHALMIA. 

such views of the disease as I have here attempted to establish. 
I might, myself, think this remark unjust, as others perhaps 
may, were it not confirmed by this fact; that even where this 
remedy has been resorted to, the general principle of aiding its 
effects by the obvious collateral means, of diet, or whatever else, 
has not been adopted; while, further, it has been used only at 
the end of a treatment where all the preceding remedies have 
been commonly pernicious, inasmuch as proceeding as a view 
of active and local inflammation, too often to be reduced by eva- 
cuations, in spite of the warnings on that head. Thus also has 
there been adopted a remedy, which, while it evinces an incor- 
rect view of this disease, must be condemned, equally for its 
apparent severity as its inutility, except in peculiar cases; and 
therefore, if safe in the discriminating hands by which it was 
introduced, not to be trifled with by those who adopt, without 
distinction or discrimination, whatever is recommended and has 
become a usage. I mean the puncturing of the eye to discharge 
the vitreous humour; while I trust that I shall not, in thus cen- 
suring the general use of this remedy, be supposed to censure 
the able surgeon to whom we must trace the recent recommen- 
dation. 

I have already said, on various occasions, that in all inter- 
mittent and neuralgic diseases, the evacuating and debilitating 
system is pernicious and that among the remedies of this class, 
the most injurious is blood-letting, both general and local: a sub- 
ject, however, which I must yet re-examine in inquiring respect- 
ing the general cure of Neuralgia at large. I did formerly show, 
however, that in remittent and intermittent fever, cases did oc- 
cur; or might be imagined, where not only a moderate use of 
such means, particularly at the commencement of the disease, 
might be innocent, but was even occasionally beneficial, and for 
reasons which were then stated. 

Thus it is in this ophthalmia, when violent, and particularly 
on the first attack; since the effect may often be to reduce the 
local disease which threatens local injury; while, though that 
remedy be really pernicious as it regards the constitutional affec- 
tion, inasmuch as it commonly renders that more obstinate, the 
evil from this cause would be as nothing compared to the possi- 
bly impending local evil. It is plain therefore that I do not ab- 
solutely exclude blood-letting, both general and local, in this 
ophthalmia, at least when recent and severe; yet I think it high- 
ly essential that the reasons for permitting its use should be duly- 
understood, as I trust they will now be by reverting to what was 
formerly said on this subject; since, thus to understand the theory 
of their application, is the only security that exists against their 
abuse or misapplication. ■ The disease must not be considered as a 
common inflammation of a local nature, reducible, from its com- 



NEURALGIC OPHTHALMIA. 377 

mencement to its termination, by the usual local and general re- 
medies of these generic affections, but as a peculiar disorder con- 
nected with, and dependent on, a constitutional disease in which 
the evacuating system is pernicious, but in which that is permit- 
ted rather than ordered, under peculiar and accidental circum- 
stances in the local affection, and as a purely local and tempo- 
rizing remedy. 

Hence it is plain that the use of this remedy calls for nice 
discernment on the part of the practitioner, though it is impos- 
sible to give more minute directions. As in every thing else 
in physic, that which is necessary, and which in reality is the 
only useful, is to master the general principles; not only to un- 
derstand clearly the general theory, but to study to apply it to 
each case; for, throughout this science and art, every case is a 
special case under some one general head, each example requiring 
its own treatment, yet every treatment bottomed on a leading 
principle; while he alone is the physician who can thus see each 
case as an individual fact in philosophy, diverging from a more 
leading one; since he alone will know how to apply his reme- 
dies, in all cases and under all circumstances. To that rare be- 
ing, the philosophical practitioner, I have already said enough, 
and more than is necessary; but I must proceed. 

Supposing this ophthalmia to have become established, or 
else chronic, the employment of evacuants becomes, not only 
useless but pernicious; and the pernicious consequences are 
often most serious. They are generally also pernicious when 
repeated after the urgent and first necessity, should that have 
existed, is past; as their tendency is to confirm and aggravate 
what they cannot cure. In practice, in reality, it will rarety 
happen that any evacuants are useful, or necessary; as a very 
large proportion of the cases of neuralgic ophthalmia are so 
slight, however apparently severe to those who view them as 
common inflammation, that no local injurious consequences can 
be apprehended. And further, it generally happens that ap- 
plications for relief are not made till the disorder has been so 
long established that the originally active state which might 
have justified blood-letting is past: so that if the empirical rule 
were universal for empirical practitioners, namely, to exclude 
the use of these remedies from every case whatever, the ave- 
rage results would produce a very small proportion of evil. 

The simplest bad effect of these remedies, is, a negative one; 
or it is, that they do not cure the disease, and that it be- 
comes inveterate or chronic, for want of the remedies that 
would remove it; possessing that tendency in common with all 
the neuralgic diseases. It is a worse event, when this inflam- 
mation seizes on the cornea or the iris; since while those reme- 
dies fail or aggravate the disorder, the consequences may be- 

48- 



37S NEURALGIC OPHTHALMIA, 

come those which have already been described; blindness, un- 
der two modes, or at least serious injury to the sight. And 
what I have said of blood-letting, applies, similarly, to sys- 
tems of purging, particularly with the neutral salts; while this 
does not exclude a rational use of those remedies, and perhaps, 
above all, of calomel; a remedy, of which the necessity will be 
particularly seen in the autumnal cases attended with biliary 
derangements, already noticed. On this however I need not 
dwell further. 

But if, under the system of blood-letting, local or general., 
or of evacuation, under whatever mode, the neuralgic ophthalmia 
often lasts for many months, or even for years, sometimes con- 
tinuing thus without interruption, it more generally subsides to 
recur again, as happens in all these disorders when established 
or chronic. And further, it will often happen, as every practi- 
tioner might see did he but look for it, that there is a positive 
aggravation of the disease produced, and sometimes very point- 
edly, by each successive application or remedy of this nature: a 
fact which might be supposed to open the eyes of the prac- 
titioners, if we did not know the power of habit in preventing 
observation, and how imposible it is that observation, can ex- 
ist without reasoning. But that the disease is also at times 
cured under this treatment, while it appears falsely to be cured 
by it, I am not about to deny; while I trust I have already am- 
ply shown that such cures, and in spite of pernicious treatment, 
occur in all the Neuralgise. These are the spontaneous cessa- 
tions of that disease which form so remarkable a part of its cha- 
racter, as they do of intermittent in the chronic state; depen- 
ing sometimes on constitutional changes of which we are igno- 
rant and at others, probably, brought about by those unobserved 
circumstances which so often terminate Neuralgia and intermit- 
tent such as change of place and habits, mental affections, the 
occurrence of other diseases, and so forth. 

And lastly I should here remark that such spontaneous cures 
of the neuralgic ophthalmia, all of them misleading the practi- 
tioner so as to make him persist in a wrong system of practice, 
often occur from a change in the place or action of the constitu- 
tional disease of the Neuralgia. Thus have I seen this inflam- 
mation cease in a single day, on the occurrence of a relapse of 
common intermittent, and that also repeatedly; as it is similarly 
replaced by common rheumatism in a limb, by that of the inter- 
costal muscles, by toothaeh, by intermittent headachs, or by 
simple Neuralgia of the face; while the practitioner, unaware of 
this connexion, imagines that he has cured the one disease by 
his remedies, and that the patient has fallen under an entirely 
new one. 

I believe that there are some local evils arising from the use 



NEURALGIC OPHTHALMIA. 379 

of leeches in the ophthalmia, which are more frequent in this 
variety than any other, such as erysipelatous inflammation and 
abscesses in the loose skin of the eyelids; but as they are of no 
great moment, I need not dwell on them. As to scarification 
of the vessels of the eye, it is a useless practice, since it pro- 
duces no effect in the disease; while it does not probably lead 
to any direct injury, and might even, in the same cases where 
blood-letting is allowable, be useful. With respect to blisters, 
they might, a priori be judged pernicious, inasmuch as they 
aggravate all the neuralgias and neuralgic inflammations, when 
placed on or near the diseased part. Such they in fact prove; 
and if less hurtful at a distance, no great benefit can be expect- 
ed from them towards removing what, in reality, is a disease 
of the whole system. 

But if I have now finished the examination of these injurious 
remedies, or Isedentia, among which I must also include low 
diet and abstinence from wine, on the principles so often ex- 
plained, I must observe that their pernicious effects are not li- 
mited to the eye alone, or to the mere local disorder. There 
are wider ones produced on the constitution, and these remain 
to be examined. They, however, are such as this mistaken 
system produces in all Neuralgiae, of whatever character: and 
they are of such a nature, so exactly those which take place in 
all the disorders of this class, and in the intermittents also, un- 
der that pernicious treatment, that they tend strongly to confirm 
that view of the character of this ophthalmia which I have here 
given. But as the more proper place for detailing them will be 
when I consider the cure of Neuralgia in general, I must defer 
their consideration, and refer the reader to that place; though I 
will here give a sketch of a single case illustrating the evil pro- 
gress of this ophthalmia under that treatment. And if I thus 
detail it, it is not because it is a marvellous or an uncommon one, 
but partly because it unites in itself all the proceedings and con- 
sequences which I must otherwise have illustrated by detailing 
three or four instances of a parallel nature, and partly because, 
from my peculiar situation with respect to the patient, I had 
the opportunity of watching, almost daily, and for a twelve- 
month, the progress of the disease and the effects of the reme- 
dies, while, very naturally, and in a certain sense, properly, not 
permitted to interfere in that which was under the charge of a 
regular oculist; since it is no novelty, that as soon as a single 
branch of physic becomes thus separated, those who used for- 
merly to be intrusted with its care, are supposed on a sudden to 
lose all their previous knowledge. I need only add, that I could 
easily quote other cases, illustrating and confirming the present 
one, where all the effects in question were produced, though not 
all to the same extent; nor all in the same patient, 



380 NEURALGIC OPHTHALMIA. 

The person in question, an artisan under the patronage and 
care of an opulent family delighting in physic, was seized with 
the common neuralgia of the face, occasionally in its more ordi- 
nary form, and at other times under that of tootjiach. I was 
permitted to cure this by means of arsenic; but after a short 
time it returned in the temple, and was then followed by a to- 
lerably severe ophthalmia, affecting the conjunctiva of the neigh- 
bouring eye, and also attacking the iris. Nothing could be bet- 
ter marked than the disorder; as it was attended with a distinct 
intermittent and quotidian cold stage, and as the neuralgia of 
the temple was equally regular; while the contraction of the 
iris was also as periodical, occurring once a day, and lasting a 
determinate number of hours. 

I attempted of course to explain my views of the character of 
the disease, while I proposed the method of cure; and with ex- 
actly the same success which I have generally had, as well with 
patients as with my brethren of the profession, for these twen- 
ty years and much more; at the manner of which I can now but 
smile, while I regret the price at which the unfortunate patients 
have so often purchased this imaginary triumph. 

The patient was therefore sent to an oculist, at that time of 
high reputation; it having been concluded, as it is still, that nei- 
ther physician nor surgeon could possibly understand a disease 
of the eye like the man of experience; such are the ideas at- 
tached by the vulgar to a word, which, if their meaning was 
the true definition of that term, would make the oldest nurse 9 
or the empiric who sees a hundred patients in a day, the best 
physician; just as he who has manufactured the most tons of 
Glauber salt and calomel in his life-time., is the most philoso- 
phical chemist. 

If, out of humanity to the unfortunate patient, I attempted 
to explain the case to the oculist, the suggestion was received 
just as I expected; and, from that time, I could but watch, for 
instruction, the progress of the case. The first effect of local 
blood-letting, blistering, and topical applications, was a great in- 
crease of the inflammation; and as the same means were conti- 
nued and repeated, the disorder became daily more severe; 
while, the Neuralgia also increasing in severity and extent, and 
the intermittent becoming much more strongly marked, it was 
declared that there was a flow of blood to the head, and so forth. 
General blood-letting from a vein, together with that from, the 
temporal artery, was therefore adopted and repeated; while after 
a certain progress in this practice, aided by more topical reme- 
dies, more purging, and more low diet, the patient became so 
ill that he could no longer attend the oculist, and was therefore 
sent to a hospital. These operations occupied about two months; 
and if I was ? after this, cut off from as frequent a sight of the 



NEURALGIC OPHTHALMIA. 381 

patient as formerly, I was easily able to ascertain, before this 
imprisonment, that he was labouring under an inveterate quoti- 
dian intermittent, with a neuralgia that scarcely left any repose, 
extreme debility with various nervous affections, and a partial 
fatuity; all of them the effects which I had gradually foretold 
to his patrons, as any one may foretel them under such practice; 
while the inflammation was such as apparently to extend to the 
bottom of the eye, from the excessive and constant pain, and 
while total blindness on that side had also resulted from the 
complete closing of the iris. 

In the hospital, all this, in the usual way justified more bleed- 
ing and more of every thing which had already proved so in- 
jurious; while the disease persevered without a single feature of 
alteration, except for the worse, during nearly three months, 
when the gradually increasing fatuity became a mania, and the 
patient attempted to destroy himself by cutting his throat. The 
attempt was however unsuccessful; and after the wound was 
healed, he was sent home, to be transferred to a lunatic asylum, 
during which interval, I was enabled, for a week cr more, lo 
see him daily. He was then in a state of melancholy fatuity, 
rather than of proper mania; while the inflammation continued, 
but in a comparatively mild state, with occasional headach, of 
apparently great severity, and still periodical, though the state 
of the intellect prevented any very accurate examination. What 
was done in the lunatic hospital, I could never discover; but in. 
about two months he died, and, as I understood through his 
wife, with the eye still in the same condition. 

If this is the report of a case of unusual severity, it is still a 
highly instructive one; since every symptom, as well as the 
general progress, was that which occurs in a greater or less de- 
gree, not only in this ophthalmia, but in every anomalous inter- 
mittent and Neuralgia, wherever the evacuant practice has been 
pursued: while the symptoms are severe and numerous, in pro- 
portion to the activity, generally, with which the remedies have 
been applied; it also possibly depending in some measure on 
the patient's constitution, and on the quantity or severity of the 
general neuralgic tendency or affection. Increase of severit} r , 
and increased persistence of the local disease, form the one ge- 
neral feature which takes place in all the Neuralgias from the 
pernicious practice in question; as, in this case, it was increased 
severity, extent, and obstinacy in the ophthalmia; while the in- 
crease of the neuralgic pain, the general constitutional derange- 
ment, the nervous symptoms, and the fatuity which followed. 
are consequences already pointed out in chronic intermitte 
with anomalous symptoms, as well as in Neuralgias in general, 
under the same treatment. If the mania is more rare, it is evi- 
dently but a further progress of the fatuity, or an aggravated 



382 NEURALGIC OPHTHALMIA. 

effect of that state of the nervous system which produces this; 
while other examples of mania from maltreated Neuralgia, or 
from that disorder generally, as well as from intermittent, are 
not wanting, as I have elsewhere shown. And if this case is a 
very perfect one, or almost a caricatura, as it may be called, 
while it is minutely true, it will perhaps seldom happen in prac- 
tice, that a patient is so situated as to be subjected to so per- 
sistent and overcharged a maltreatment. 

Further, which is not the least important remark to make on 
it, there cannot easily or often be a medical spectator to watch 
the progress of such a case as a mere witness; while, if the 
treatment is as little suspected to be the cause of these evils as 
the disorder itself is misunderstood, it is very plain that hun- 
dreds of such cases may occur, or may be occurring every day, 
in some degree or other, totally unsuspected; that nature, or 
disease, will be accused of what is the physician's own work, as 
happens throughout all medicine, and still more, that as no oph- 
thalmia is suspected of such connexions or consequences, the 
accusation will fall on diseases of the brain; on disorganization 
of some kind, or on the extension of inflammation through the 
optic nerve, as has in fact been said, or lastly perhaps, on an ori- 
ginal and independent tendency to Mania. 

This remark is not trivial: it is, on the contrary, a most im- 
portant one, while it applies to every evil event or bad termi- 
nation in the whole of these affiliated diseases, whether ranking 
under Neuralgia or Intermittent, and while a long inspection of 
practice has proved to me that such events, so misapprehended 
as to their cause, are numerous and common. It applies indeed 
to much more in physic; since it must do so to every case, of 
which the nature is not understood, and where the bad result, 
while it is the consequence of ignorance, acting negatively or 
positively, can never be so considered, because of that very ig- 
norance; which, as it originally caused the wrong, must for ever 
prevent such wrong from being discerned, and also from being 
rectified in future. Prescience is knowledge: among mortals 
there can be no other ground of it; or, in action, knowledge is 
prescience: and it is only he, in those cases, who could foresee 
the whole train of events, who ever can know, retrospectively, 
what has been wrong; while it is evident, that not to be capable 
of discerning this, is an assurance for the continuation of such er- 
ror; as it equally follows, that in the hands of him who possesses 
this prescience, such events can never occur. Thus it is that he 
who produces wrong, justifies himself on the plea of fatality or ne- 
cessity, and persists, through all the conduct of life, as in phy- 
sic; while such evil can never occur to him who, in foreseeing, 
prevents; and to him, therefore, it will always be supposed that 
such evil consequences were not allotted in the order of things. 



SvEURAL&IC OPHTHALMIA. 383 

If right conduct is thus, in the ordinary affairs of life, called 
good fortune, as, reversely, wrong conduct through ignorance 
is considered evil fortune, so it happens in physic, that no ap- 
probation attends him who has seen and prevented, since the 
conduct which did prevent is unknown and unseen; as the event 
that would otherwise have followed is equally unforeseen, and 
from the same ignorance: while excuse at least is ready for him 
who, suffering evil to happen, or causing it, has, under the same 
ignorance, been thought merely unfortunate. And thus also 
does it happen that the greater fame follows him under whom a 
disease has been most severe: as this ignorance knows not that 
he has been the cause of the severity, and equally treats with 
contempt the physician of a slight case, not knowing that it was 
his discernment that rendered it such. Under such inverseness 
of conclusion must the sound physician, however, submit to 
discharge his conscience; while it must be hoped that he will 
feel that his sufficient reward, since it is the only one that he is 
likely to inherit. 

It is plain now, to return, on merely moral considerations?, 
that if this instance, as an entire case, is solitary, it could not 
possibly be otherwise, unless a similar witness had watched such 
another, since assuredly he could not suffer it under his own 
management; and further, that it will and must be solitary, till 
the present views of this disease begin to be established, since, 
let it occur ever so often, it will never be suspected to have been 
thus caused: while, further, still, whenever such views shall be- 
come universal, it can occur no more, as no practitioner would 
suffer a disorder, the cure of which he understood, to proceed 
to such extremity, and could scarcely thus watch it in the hands 
of another, without an interference which would then be easy, 
as it is, assuredly, far otherwise at present. 

Such are the explanations which I have thought it necessary 
to give respecting a case which might be supposed useless, as 
being either solitary or accidental, or else ill explained; and I 
shall be much surprised if, when those who really can review 
their own experience (a talent not the lot of all) shall review it, 
they do not find facts to illustrate what I have said, and to con- 
firm, even perhaps by cases absolutely parallel, that which I 
have here narrated. 

I can indeed conceive that the production of Mania in this 
case will, by those who are yet ignorant of the real nature of 
Neuralgia j be attributed to hereditary disease or to other causes; 
or at least that those who are yet unconvinced respecting the 
real nature of the ophthalmia, will deny that it could have been 
the effect of the evacuations. But while it is not the only ease 
of mania which I have seen thus produced in Neuralgia, though 
fatuity is the more common result, and while the probability is 



384 NEURALGIC OPHTHALMIA. 

confirmed by what I have said respecting mania from these 
causes in another place, Sauvages has described a case where the 
evacuation of the aqueous humour (the process recommended 
hy WardrOp,) was followed by mania. Not that I conceive this 
operation to have been the cause, since, on the contrary, from 
his erroneous views respecting the disease, there can be no doubt 
that it had been treated, altogether, like my own case, by the 
usual system against active inflammation. 

But it will not be useless to notice another case, though of a 
Very different character; because it is of that kind which is most 
common, and which, in fact, is. perpetually occurring in prac- 
tice. And I have the same opportunity of describing it; that 
which cannot very often happen to any one; namely, that I 
knew the patient intimately through the whole period, but was 
not consulted, very properly, as not engaged in the practice of 
physic or surgery. In the family to which this individual be- 
longed, all the members, with one exception, suffered an inter- 
mittent, from a temporary residence in a pestiferous part of 
England, which eventually proved incurable, destroying also 
two of the patients; this person alone having the disease in an 
almost undiscernible form, but being affected with the charac- 
teristic inflammation of one eye; a further instance, were one 
necessary, how one malaria will produce different diseases in 
different persons, as it is a proof that it will produce this par- 
ticular disorder. The oculist, of course, was referred to, in 
spite of such explanations and remonstrances as were practica- 
ble, and the usual practice was followed and persisted in. The 
consequence, as might be expected, was a general loss of health, 
which was not restored till some years after this operator had 
been dismissed : at the same time, the sight was destroyed, 
through an increase of inflammation that seemed to occupy the 
whole organ, finally reducing it to half its size; and at this mo- 
ment, after nineteen years, it continues inflamed, though occa- 
sionally becoming pale, or entirely losing its redness. Such, 
but in very different degrees, is a very common result of the 
original maltreatment of this inflammation: and of this charac- 
ter, we may be almost sure, is every instance where habitual 
ophthalmia occurs in any individual. 

Respecting the cure of this ophthalmia, I have left little to 
say, after thus examining the wrong and common system of 
treatment; while though the general cure of Neuralgia is re- 
served for a separate place, I cannot well avoid pointing out 
what is further requisite in this disorder, as I was compelled to 
do in the instance of toothach. 

How far, general, and even topical bleeding, is admissible, 
rather than valuable or useful, I need not now repeat. It will 
not cure the disease, under any form, is always pernicious if 



NEUBALGIG OPHTHALMIA. 385 

persisted in, in the acute cases, and invariably so in the chronic 
ones. With respect to emetics, purgatives, and sudorifics, their 
utility and value are to be understood from what has been said 
of them in treating of the marsh fevers; for the constitutional 
disease is the same, and the same must the treatment be. And 
thus also we can see in what manner undue purging must be 
mischievous; in acute cases as well as in chronic ones; and how, 
especially in the latter, it may bring on relapses; as these also 
will be produced, just as they are in chronic intermittents, by 
any debilitating causes. 

Of the topical applications I must observe, that there are, 
even acute cases of this disorder, sufficiently teasing to the pa- 
tient, and even alarming to timid ones, where the mere local use 
of stimulants does alone remove the disorder; the constitutional 
affection in such instances being perhaps trifling, or even, it may 
be supposed, nothing; or else disappearing spontaneously, or 
from slender changes of circumstances, as intermittents them- 
selves, equally slight, so often do. In such cases, I know not 
that any thing is more efficacious than hot water, as hot as it can 
be endured; while in the chronic relapsing attacks it is often 
sufficient alone to the cure. In ail these cases, acute as well as 
chronic, persistence is most necessary: but in saying this, I must 
also remark on a mistaken and injurious practice, not very rare, 
namely, that of applying ice; while I ought to say, generally, 
that cold washes of all kinds are either useless or mischievous. 
In the chronic cases also, especially, very strong metallic solu- 
tions, such for example as sulphate of zinc, in the proportion of 
ten grains to the ounce of water, often remove the inflammation; 
while this particular class of remedies also dissipates the opaci- 
ties of the cornea, unless caused by pustule or ulceration, or un- 
less very dense, from repeated attacks. No incurable opacity 
from mere inflammation in this disease, ought in fact to exist: 
and when it is not prevented or cured, there has been neglect 
somewhere. Of other applications, opium, both within and 
without the eye, is often also useful: but let me remark here, 
that its chief, or almost sole value, is when applied on the sub- 
siding of the paroxysm, or during that remission which can al- 
ways, with care, be discovered: diminishing thus, as in all the 
neuralgic affections of tender parts, that soreness, or pain, or un- 
easiness, which persists after the proper paroxysmatic attack has 
passed away. Thus is also the internal use of opium useful in 
the same circumstances. As far as this substance is of use as an 
application in the chronic cases, it must, I think, be classed with 
the stimulant remedies already mentioned. 

Lastly, in all the modes of this disease, that is, in the chro- 
nic ones at all times, and in the acute, whenever the febrile state 
permits, or when such evacuation as may be iudncd necessary 

19 



3S6 NEURALGIC OPHTHALMIA. 

has been premised, the remedies are those of intermittents and 
neuralgia; namely, Bark, and the tonics, under all those regular 
tions which I need not again discuss; though I ought to remark, 
that in numerous cases of the long continued and relapsing dis- 
ease, and in many indeed of the acuter or more severe ones, 
and even when of some standing, I have found both arsenic and 
bark eminently successful without any other aids, while rarely 
failing to cure a new case within even a few days. As usual in 
all other cases of Neuralgia under every variety, the inflamma- 
tion has been more tantalizing, and the remedies less actively 
efficacious, as it has been of longer standing and more subjected 
to a previous course of maltreatment; though I can scarcely, witk 
any effort, recall a case to mind, of whatever character, which 
was not cured, when the patient's confidence corresponded to 
my own. These, in reality, are the true remedies of this oph- 
thalmia: a fact which if it had been always known, would have 
saved thousands from blindness as from suffering; and not only 
so, but from broken constitutions or even worse evils; since the 
long persistence of this disorder produces the same effects as the 
similar duration of any intermittent or any Neuralgia. And in 
the inveterately chronic cases, if these fail, we have little re- 
source but in that change of air and habits which, as to inter- 
mittent, has already been examined. I need not add the use of 
a good diet and of wine: having even cured some cases by those 
means alone, where the disorder appeared to have been protract- 
ed by the opposite system. But I must regret, in terminating 
this brief sketch of the treatment, that I have never had any 
opportunity of attempting to suspend or stop the disorder by 
that stimulant treatment which so often cures the ordinary in- 
termittent: partly from the difficulty of obtaining a case at the 
commencement, and partly from the prejudices of patients. 
That it does deserve a trial, I must, however, think; and shall 
be glad to find that others have attempted it, and, as I cannot 
help anticipating, with success. 

For a minuter examination of these remedies, I must refer to 
the general discussion on the treatment of Neuralgia hereafter; 
but I cannot terminate this chapter without a criticism far diffe- 
rent from those which 1 have so often been compelled to make: 
as grateful as those have been painful. If I have not adopted 
Mr. Wardrop's recommendation of evacuating the aqueous hu- 
mour, it is because I hope that the necessity for this will never 
again occur; but it is pleasing to observe how a man of acute- 
ness and talent will discover a right system of cure from his own 
unassisted observations, and even under the difficulty of con- 
tending with an imperfect or a wrong theory. I need not point 
out how nearly my own mode of treatment corresponds with 
his ? while each has been formed independently, and on different 



CONNEXION OF NEURALGIA AND INTERMITTENT. 387 

grounds; nor what confidence is due to this treatment, when the 
one had arrived at it through a theory, and the other through 
the road of mere experience, without one. 

And I should not do justice to the value of theoretical or sci- 
entific proceedings in physic, did I not also point out this as an 
instance of the utility to be derived from generalization, when 
the analogies are justly drawn and the induction legitimate; since, 
whatever doubts may continue to be entertained respecting the 
truth of the views contained in this essay, as to toothach or 
aught else, that truth is, in this case, proved by this important 
and unexpected coincidence, and by the success of the practice. 
I may well, therefore, esteem the Essay on Rheumatic Ophthal- 
mia to which I allude; since, independently of its intrinsic uti- 
lity, it is, to me, especially of importance; while I even hope 
that the description of this peculiar affection, as here given and 
thus supported, may go far towards gaining credit for the whole 
theory of Neuralgia. 

I indeed trust that the value of applying to physic the usual 
philosophical processes which have so eminently succeeded in 
the other sciences, has long ere this been apparent; since, if any 
useful truths have been established, it is entirely owing to that 
most simple and obvious mode of proceeding, as I was in pos- 
session of no facts that were not common to all physicians from 
all times. It is a machinery which all can equally command if 
they please; and which, if it has not been used as largely in the 
science before us as it ought, has apparently been neglected from 
a sort of tacit concession, or belief, that physic was not yet in 
a state, as to facts, thus to profit; from forgetting that what has 
been often, and justly, called the New Philosophy, was applica- 
ble, here, as to all the sciences; and from proceeding on a basis 
derived from the infancy of physic exclusively, not from the 
maturity of science at large. 



CHAPTER XIX. 



General Remarks on the Connexion between Neuralgia and 
Intermittent. 

I have now completed the account of all the diseases which 
I had proposed to rank under the general heads of Intermittent 
and Neuralgia, as far as my own observation has furnished me 



3SS CONNEXION Of 

with evidence to this purpose. The list is a long one, and hag 
probably proved a very unexpected one to my readers; and yet 
I am far from believing that I have exhausted the subject, or 
that further observation will not discover that there are other 
disorders which may with equal justice take rank under this ge- 
neral head. But this I must leave to future observers; having 
determined not to overstep the evidence, since I know of no 
philosophy that is not founded on facts. I will not even ven- 
ture to suggest what I think possible, or likely, from general in- 
duction redirected to particulars: as, esteeming Theory with 
every one who understands the real meaning of that term, I 
consider that it has no greater enemy than hypothesis; eternal- 
ly as those two most opposed terms are confounded by the vul- 
gar of all ranks. 

As to the proofs by which I would establish a community, in 
the first place, and a generic one, between Intermittent and 
Neuralgia, and in the next, among the subsidiary local diseases 
under Neuralgia, they have been so necessarily given during the 
preceding descriptions, or have so arisen out of the very ac- 
counts of symptoms and treatment, that, to go over them all, 
again, would be to produce either a meagre abstract or a tire- 
some repetition. Yet, perhaps, this hazard must be incurred to 
a certain extent, for the sake of those who may not have car- 
ried the arguments along in their own minds; while I have also 
a few facts to add on this subject, which could not, hitherto, ea- 
sily have found their places any where, without producing di- 
gressions, or interrupting the order which I thought it necessa- 
ry to adopt in conformity to the existing opinions and prejudices. 
These I shall state first; selecting, however, but a few T of the 
most conspicuous from a considerable number, as examples of 
the whole. 

If I have shown that all the diseases treated of in this essay- 
do arise from Malaria, while at the same time I have not ex- 
cluded the simple action of cold as a cause, while I have shown 
that local injuries will produce Neuralgias, and while also I do 
not deny that there may be yet other causes, unknown to us, it 
will be a strong proof of a community in the nature of these 
disorders, to find that the same decided and ascertained cause. 
Malaria, applied, in the same place or places, to many different 
persons, produces the whole of them. It would be tedious to 
enumerate all the cases of this nature which have occurred to 
me, as it would require a considerable number to embrace all the 
disorders here described; but I will quote one as an example of 
my meaning on this subject, chiefly because it is a very extensive 
one, and that my means of ascertaining the facts were perfect. 

In this case, the situation was so decidedly subject to 
Malaria, that scarcely an individual, out of many different 



NEURALGIA ASD INTERMITTENT. 389 

families which had resided in it, had escaped intermittent at 
some period of their stay. In one season, and in one family- 
consisting of twelve or fourteen persons, the following were the 
effects in as many individuals. One tertian; one double quoti- 
dian headach; another tertian; one diseased spleen; in one indi- 
vidual, aged only eighteen, a temporary hemiplegia with ob- 
scure quotidian; a second case of palsy in one leg in a person of 
twenty, with obscure quotidian and symptoms of diseased 
spleen: a regular Neuralgia of the face, of double tertian type. 
In a following, distant, season, and in some of the same per- 
sons, there occurred; palsy of the face with imperfect speech^ 
an attack lasting beyond a week, and replaced by quotidian 
neuralgia (Tic;) a double tertian, common intermittent, termi- 
nating in a quotidian, or double tertian, neuralgia; a quotidian 
with neuralgia in the shin bone; the same patient having had, in 
a preceding season, a common tertian so obscurely marked, that 
he was ordered to Italy for a consumption, (a consumption 
which was cured by two ounces of bark and a change of place 
to ten miles' distance,) and in a following one, having been at- 
tacked again with a double tertian, of which one fit was attend- 
ed by the neuralgia of the shin and the other by a headach. 

This particular instance, it will be seen, embraces a consider- 
able number of varieties under the two heads of Intermittent and 
Neuralgia; while I might even have extended it, by adding 
what occurred in other seasons, in the same place; among 
which I might have enumerated an irregular intermittent with 
neuralgic palpitation of the heart; an acute hepatitis (probably 
dependent on the same cause;) two instances of diseased spleen; 
one of Neuralgia, with obscure intermittent, in the foot; one of 
periodical toothach with double quotidian; one of periodical 
quotidian rheumatism in the arm: one of quotidian with irrita- 
bility of the bladder: a second, of very severe neuralgia of the 
heart, replaced and cured by a common quotidian; and one of a 
periodical general chronic rheumatism, of a most defined type 
and quotidian character. 

This is an example, altogether, of the species of evidence to 
which I here allude; nor can there be a rational doubt that the 
same cause, acting on different persons, produced all these dis- 
orders, particularly as, in some of the individuals, a different 
season produced a different one from what a preceding had 
done. I cannot, it is true, adduce another case so extensively 
inclusive; though I have little doubt that analogous or similar 
ones will be found by those who shall seek for them. And if, 
by going through my experience, I could find analogous exam- 
ples, cases where common intermittent and one or more of it? 
anomalous varieties, as well as of Neuralgia, had occurred in 
different individuals, — simultaneously, in one house or situ?,- 



590 CONNEXION OF 

tion, so as gradually to embrace every disease that I have here 
treated of, the enumeration would be tedious, while it could 
scarcely add to the conviction of those who agree with me, and 
would assuredly make no impression on those who refuse the 
evidence which I have already produced. 

On this class of evidence I must however make the following 
remark. If I think that it can easily be verified in the un- 
healthy districts of England now that the facts and the theory 
are pointed out, and if I also think that it will be so confirm- 
ed, it is even more probable that this will be effected, with 
even greater ease and in a greater mass, in the pestiferous dis- 
tricts of France and Italy. It is true, as I formerly observed, 
that the physicians in those countries have overlooked Neural- 
gia altogether, even in its best marked and simplest form; as 
they have not produced one general conclusion such as I have 
here drawn, respecting any disease which was not pure and 
perfect fever, though casually noticing some of those. But it 
seems to me so impossible that the class of facts which I have just 
brought in evidence should not exist in those countries, that I 
shall scarcely hesitate in saying, that while I rely on their be- 
ing so confirmed, if ever these opinions should reach so far, I 
am content to rest the whole question on that issue. 

To this general species of evidence respecting the community 
of all these disorders, as far as that can be proved by communi- 
ty of cause, I may next add, that which consists in the fact of 
all or a great number of these diseases, from common remittent 
and intermittent through all their anomalies, down to Neuralgia 
in all its modes and forms appearing in one individual: alter- 
nately replacing each other or succeeding irregularly, or else 
variously combined. I formerly noticed this fact; but it is suffi- 
ciently important to be again pointed out under this head of 
general evidence. 

Herej as in the former case, I could, and without difficulty, 
produce instances enough to prove, from different individuals, 
the mutual connexion and community of every disease that I 
have described: by showing that, in some one person, two, 
or three, or four, or five, or even more forms, have been united, 
er have succeeded to each other in such a manner that the new 
disease formed the cure of the preceding, or the substitute for 
it. But this would be, again, to produce a tedious list of cases; 
while, as before, I could not expect to gain converts among 
those who will not be convinced by a single case, and while I 
consider such accumulation of evidence superfluous to those 
who will feel the value of one, selected from the whole, as the 
former has been on account of its extensively inclusive nature. 
And I may add, as to the case which I have selected, that my 
habits of intimacy with the individual during a long course of 



NEURALGIA AND INTERMITTENT. 3D1 

years, enabled me to verify the fact in the most satisfactory man- 
ner. It is the history indeed, as to this point, of nearly thirty 
years; since thus long was this person the victim of the diseases 
of chronic intermittent, or of this disease in its simple form as 
well as its anomalous and more purely localized ones. 

In mere fever, this patient experienced various remittents, to- 
gether with tertian, double tertian, quotidian, and double quo- 
tidian, in different years; and, in the anomalous varieties, what 
may perhaps be referred to the Asthmatica, and to the Strangu- 
riosa, and also what may possibly be the Nephralgica of Sau- 
vages; together with the Emetica, the Hysterica, and the Sopo- 
rosa, of the same arrangement. These intermittents also, at 
different times, were united with, or succeeded to, or were re- 
placed by, periodical and marked general chronic rheumatism, 
periodical local rheumatism in a limb, and rheumatism of the 
face, with repeated slight attacks of the ophthalmia of one eye, 
attended by hemicrania. In simple Neuralgia, this patient also 
experienced that of the face, repeatedly, long relapses of pure 
hemicrania, clavus, that of the eye, or optic nerve, sciatica, and 
a similar affection in one radial nerve and in the anterior crural; 
as, on different occasions, he suffered quotidian intermittent 
toothach, and the most severe neuralgia of the heart which I 
have ever witnessed, recurring annually for many years, re- 
placing, once, a local periodical rheumatism, and more than 
once replaced and cured by a quotidian simple intermittent. 

This is probably a rare case of severity and multiplicity, as 
the case itself was remarkable for its inveterate duration; but I 
doubt not that it can be paralleled, if not equalled, by the expe- 
rience of others. But it is plain that it can be so paralleled, 
only by taking the same views of these diseases as myself; since, 
under the present opinions, most of those would have been con- 
sidered as independent disorders, accidentally meeting in a sin- 
gle subject. There will, also, always be a difficulty in studying 
such extreme and durable cases; as no one patient would pro- 
bably so long persevere with a physician, since he would natu- 
rally attribute incapacity to him, finding no cure: and it is this, 
(very natural surely,) versatility of patients, which will always 
form a check to the study of cases of this nature. But as far 
as relates to this one, or to such minor instances of the same 
kind as 1 have declined recording, that I may not prolong this 
branch of evidence, there seems as perfect a demonstration as 
physic can ever be expected to produce, that, all the diseases 
enumerated arose from one leading cause, or were, all, the dis- 
tinct demonstrations of a general disorder, or habit, rooted in 
the constitution. 

To these two general branches of evidence, consisting in com- 
munity of cause, and in coexistence and interchangeablcness. I 



392 connexion of 

may now add a third, founded on the effects, whether for good 
or evil, for cure or aggravation, produced by remedies or modes 
of treatment as to all these disorders. Throughout the whole 
catalogue, it is to the same class or system of remedies that we 
must look for the cure; while it is further remarkable that these 
are all remedies acting on the constitution. Whether it be a ge- 
neral disease or a local one, let it be even as purely local as pos- 
sible, and let it be mere pain, or else inflammation, and in what- 
ever part of the body, we derive no advantages, or very slender 
and partial ones, from local remedies; while we must cure the 
disease, if we do cure it, by those general ones which are 
equally the remedies of an intermittent occupying the whole 
body and without any local tendency or symptom. And if re- 
medies that are not medicines, such as change of air and habits, 
such as mental impressions, such as are even charms, act in re- 
moving simple intermittent, thus do they act similarly in re- 
moving the local diseases in question, even down to a common 
toothach. If we had no other proofs that all these disorders, 
that even a disease so apparently simple and purely local as a 
toothach, were truly constitutional, this would be proof enough; 
as, in no other mode than as affecting a constitutional derange- 
ment, could a few doses of bark remove a disorder of this na- 
ture. 

Certainly, that many diseases are cured by one remedy, is 
not, by itself, a proof that all those diseases are of the same na- 
ture; but in the present case, and combined with the former evi- 
dences, the fact in question adds a strong confirmation to the 
present views; which are also further confirmed by observing, 
that the same system of treatment which is injurious in any one 
of these diseases, is injurious in all the rest. And this is true, 
whether they be local or general: or, the treatment which is 
pernicious in simple intermittent, is pernicious in all the anoma- 
lous and local diseases alike, and in the Neuralgias as in all else; 
while, very remarkably, where those improper remedies are the 
remedies of inflammation in general, they are injurious in the 
particular inflammations that appertain to this set of diseases. 

It is still more remarkable, that the evil effects produced by 
such wrong treatment are the same, or similar, whatever may 
be the particular form, or disease, out of this entire catalogue, 
for which it is administered. Whether it be an intermittent of 
the most ordinary character, whether it be an anomalous one, or 
should it be any of all the neuralgic diseases, however apparent- 
ly local and simple, it is the constitution, or the system at large, 
which suffers from that improper treatment, and in the same 
manner; while as far as the local, or even the general disease 
may suffer, it is, in all, also, in the same manner; namely, that 
they become confirmed or aggravated, or acquire a tendency to 



NEtTKA£«lA AN3> INTERMITTENS. 393 

recur when they would otherwise have terminated. No greater 
proof could easily be offered that these diseases were essentially 
constitutional, in all their forms, and dependent on a radical, 
concealed, general cause, or morbid condition: or, at any rate, 
this fact confirms strongly all the other proofs already offered in 
support of that view. 

What these effects of improper treatment are, and what the 
treatment itself to which I here allude, is, have been pointed out 
in various places. But to complete this part of the general evi- 
dence, I may repeat generally, that the injurious treatment con- 
sists in the debilitating system, or in low diet and evacuants, 
among which blood letting holds the place supereminently mis- 
chievous. And be the disease what it may, be it general, local, 
or even inflammatory, the effect of such treatment is to produce 
or aggravate general debility, to induce a variety of nervous 
symptoms, which I need not enumerate particularly, and, in 
proportion as it is perseveringiy or violently pursued, to bring 
on paralytic affections, fatuity, even mania, with irreparable bad 
health, and unquestionably, if in extreme excess, death. 

If, with ail this in addition to what has preceded on the same 
subject throughout the whole of this essay, I conceive that I 
have made out my case, by evidence even to superfluity, I must 
still perform my promise by a brief extract from the whole. 
And this is perhaps necessary; because I must not forget that an 
individual without name and without authority, unknown as a 
medical teacher or writer, not even engaged in practice, places 
himself in a difficult and hazardous situation, when he doubts 
or condemns what has been, and is believed and practised by 
the thousands, his predecessors and contemporaries, of name and 
reputation to which he has no pretensions. But, at every ha- 
zard, he who conceives himself right, is bound to declare what 
he thinks to be supported by evidence; particularly where so 
deep and wide an interest as that which concerns the health or 
suffering of mankind at large is at stake. It is a case where si- 
lence would be deeply criminal; while, if he is right, all will 
gain, whereas, if wrong, he will be the only sufferer. And 
should he prove, in the end, to be right, all that will follow as 
to the past, is, what has been, through every thing, the history 
of the world; that the force of habit and example, while it forms 
the whole philosophy and the sole rule of vulgar minds, is such 
as to influence even the most powerful ones, and thai, from 
whatever cause, persons are not often found who will discard all 
that they have been taught, to form new opinions; still less, who 
will venture to declare their opposition to opinions and practices 
long received. 

Yet in all that appertains to human life, not merely to science, 
such a lot must be that of some one. There must be an indivi- 

50 



394 CONNEXION OF NEURALGIA AND INTERMITTENT. 

dual, in every thing, who will doubt or disbelieve what he has^ 
been taught, and what others believe; who will form conclusions 
and opinions for himself out of the facts around him, and by 
his own reasoning; discarding those of his predecessors and con- 
temporaries. Were it not so, had every man believed what h© 
had been taught, the world would now be what it was in its 
childhood: but as he who ventures on a new path must oppose 
all, it is his necessary fate to be too often opposed by all, and to 
find but hostility when he hoped for support. 

The abstract in question is therefore the following, passing 
over the community of remittent and intermittent fevers, as an, 
admitted fact. Intermittent fevers arise from Malaria, cer- 
tainly, as principally, and from mere cold possibly; but are re- 
newable by mere cold, when once they have existed. 

They are often attended by peculiar local symptoms producing 
the anomalous varieties, while, when the febrile state is slight 
or obscure, these local disorders appear to be the chief disease. 

Such local disorders are either affections of the nervous sys- 
tem, or of an inflammatory character, and they have been fully 
described. 

The same intermittent fevers, more or less distinct, are ac- 
companied by all the Neuralgias that have been described, whe- 
ther these consist of simple pain, or are attended by inflamma- 
tion; and when the febrile state is slight or obscure, those local 
affections appear to form the chief disease. 

If intermittent fevers alternate with all the anomalous local 
symptoms or diseases, so do they with all the neuralgic diseases: 
and in such cases, the supervention of one is the removal of the 
other. 

Thus also, all those local diseases, including all the Neural- 
gias, alternate with each other; or the appearance of one form is 
the cure of a preceding one. 

Many of the Neuralgias will exist almost simultaneously, or 
else in alternating paroxysms; these having any of the types of 
intermittent. 

They also exist in alternating paroxysms with simple inter- 
mittent: or a particular doubled type will consist alternately of 
a paroxysm of pure fever and a paroxysm of Neuralgia. 

The same individual under a persevering intermittent, will 
experience many of the anomalous forms of that disease, and 
also many of the neuralgic diseases, in alternation or succession; 
or else in union; and, in such cases, the type, and the hour of 
recurrence, will be the same for all the forms, even through a 
long course of years. 

Malaria will produce the neuralgic diseases directly, as pro- 
bably, will mere cold; but they are renewable by mere cold 
when once they have existed; and in these cases, though the in- 



CONSEQUENCES OP, &C. 395 

iermittent fever is probably always present, it may be so slight 
as to be overlooked. In this, the first cause, Neuralgia, in all 
its forms, resembles intermittent: but it differs, inasmuch as it 
can be excited by direct injury of a nerve; a difference, howe- 
ver, which is of no moment as to the general identity, because 
we know of no means of thus injuring the entire nervous sys- 
tem so as to produce general intermittent. 

The same Malaria, in the same spot, acting on different indi- 
viduals at the same time, will produce either intermittent or 
Neuralgia, and every form of each. 

Intermittent and Neuralgia, in all their forms, are cured by 
the same remedies, and injured by the same wrong treatment; 
and those remedies are constitutional ones, whether the diseases 
be local or general; while, very particularly, the local and the 
general diseases both, are cured by operations on the imagina- 
tion. 

The conspicuously wrong treatment for all of these diseases, 
whether Neuralgias or intermittents, consists in the debilitating 
practice, as the right treatment is found in what is esteemed the 
reverse; and whatever be the disease, be it local or general, 
when that practice is pushed so far as to become injurious, the 
injury is always of the same character, affecting the entire ner- 
vous system. 

Such is the summary view of the evidence; and I must now 
proceed to some circumstances belonging to these diseases, 
which may, in one sense, be looked on as consequences, in ano- 
ther, as modes, of them. 



CHAPTER XX. 



On certain Consequences of Intermittent or Marsh Fever 
and Neuralgia. 

If I have placed here, as consequences, some symptoms or 
diseases which belong to the subjects treated in this essay, it is 
not, as 1 just insinuated, that I am quite satisfied with viewing 
them in this manner. Yet they could not well have found a 
place as mere modes of Neuralgia, since they are generally the 
sequels of a previous painful state. But when I have been una- 
ble to venture any where on the order that I should have ap- 



396 CONSEQUENCES OF 

proved, T must be content to suffer this additional irregularity 
in the hopes that, at some future time, I may be allowed to adopfc 
a more consistent view of the whole subject. What I have to 
say, however, is little more than a repetition of some circum- 
stances already noticed in the former description; though it was 
not the less necessary to allot them a distinct place. 

I formerly showed that intermittent fever sometimes attacked, 
directly and primarily, in the form of apoplexy, and further? 
in that of palsy, affecting different parts, and being more or less 
extensive. Further, in the progress of such a disease, there oc- 
cur paralytic attacks, either sudden or gradual; being, in the lat- 
ter case, generally incomplete. Hence therefore the palsy may 
be considered both as a sequel and a mode; being the conse- 
quence, in one case, of the gradual action of the fever in a local 
direction, and, in the other, being a local disease or symptom, 
attached to the general one, analogous to what happens in other 
cases with anomalous and special symptoms. 

Now both these events also happen in simple Neuralgia; 
though as far as I have seen, it is rare for the paralytic symp- 
toms to precede the painful ones. But when this does happen, 
the primary attack is a numbness, or a more complete palsy, in 
the nerve which is about to undergo the pain; and this follows 
after some time, either relieving the palsy, or being accompa- 
nied by a certain degree of it. Hence, I presume, we must 
consider the palsy as a mode of the neuralgic disease; a partial 
affection, analogous to the apoplexy or greater palsy which com- 
mences the attack of common intermittent. And if, as I for- 
merly suggested, amaurosis should or does occur from cold or 
Malaria, yet without a marked intermittent fever, this would 
be an example of that nature, of a perfect and simple kind. 

But in the case of Neuralgia, it is far more common for the 
palsy to be a sequel of the painful state; and if it is rare in cases 
of short duration, it is by no means uncommon in those of long 
standing. In such instances, it is commonly gradual, com- 
mencing with a numbness; though occasionally also it is sudden; 
while in both cases, the pain generally ceases, perhaps to return 
no more; sometimes, however, alternating, or occurring occa- 
sionally. Further, such palsies are generally confined rigidly 
to the parts which receive their nerves from the affected trunk 
or branch beneath the diseased or pained point; a circumstance 
sufficiently familiar in sciatica; though it also happens, especial- 
ly under wrong treatment, that it extends so as, from a palsy in 
the cheek, to become one, perhaps in the whole arm; or even 
an entire hemiplegia. Lastly, should a palsy of this nature 
be extensive or durable, and particularly should it have been ex- 
tended or produced by blood-letting and the remainder of this 



HARSH FEVER AND NEURALGIA. 397 

Ireatment, it is very commonly attended with diminution of the 
intellectual powers, or with modified fatuity, or even, as I shall 
immediately indicate more fully, with absolute loss of intellect. 
But if fatuity follows palsy in these cases, so is it produced, 
simply, or without previous paralytic consequences, in all the 
Neuralgise; whether from the action of the general disease itself 
on the system, or from that aggravation of debility in the brain, 
or general nervous system, which is the effect of improper treat- 
ment. The cases of this nature are, in fact, precisely similar 
to those which occur in intermittent, as might now indeed have 
been anticipated; adding proof upon proof respecting the radi- 
cal and essential similarity between these two classes of disease^ 
and strengthening every analogy in every light in which these 
can be examined. Such cases surely must have occurred to 
practitioners familiar with Neuralgia; though not improbably 
so far mistaken or overlooked r as to have been attributed to some 
other and accidental cause; while I need not again urge, as I 
suggested formerly respecting the effects of blood-letting, that 
while they would naturally escape notice among the common 
people, there must always be numerous instances also among 
the better ranks, in practice, where the physician's want of in- 
timacy with the patient's intellectual character and pursuits, 
still more the general inattention and the not very overpower- 
ing discernment of the great mass of ordinary practitioners, 
would prevent them from discovering the fact; while where 
there was but a small portion of this faculty previously present, 
the diminution of that little would be scarcely an appreciable ac- 
cident; so very little intellect is sufficient to carry the majority 
of mankind through their ordinary duties in the world. 

Nor is it difficult to comprehend, at least in a broad view, 
why fatuity should be a consequence in these disorders, of what- 
ever nature: since there cannot fail to be an analogy between 
the loss or diminution of the nervous power as that is employed 
in maintaining the communication between the mind as a meta- 
physical Ens and the instruments of sense and motion, and that 
diminution as it relates to the action of the mind respecting those 
impressions, or respecting its application of them. And the 
very fact itself is amply proved by the fatuity, in various de- 
grees, which does actually accompany palsies; on the whole of 
which question I shall have occasion to make further remarks 
hereafter. 

And before I quit this branch of the subject, let mc introduce 
a fact or two relating to the general affection of the nervous 
system in Neuralgia, which did not occur to mc where it might 
perhaps have found a more appropriate place: it is too impor- 
tant to be omitted. It is the effect which this disorder has in 
destroying the energy of the mind, and extinguishing the cou- 



39S CONSEQUENCES 01? 

rage even of those habitually brave and reckless. This is a con- 
fession which I have received from many persons, but from no 
one so strikingly as a Spanish officer of high rank, who had been 
engaged in the most perilous situations during the long war in 
that country, and who acknowledged that he had immediately 
become an absolute coward, while fully aware of the cause, 
from an attack of the Neuralgia of the face. The disease in 
this case also lasted long, while this ardent spirit had become 
almost a woman, shedding tears on every, the slightest occasion. 
The same effect in reality follows all the intermittent diseases 
when become chronic; while if the political consequences are 
often curious and important subjects of speculation, as they re- 
late to nations, I must reserve them for some proposed addi- 
tions to the essay on Malaria, should an opportunity occur. 
How these chronic fevers may affect individuals, there are thou- 
sands who can acknowledge; if there are not many who are as 
yet aware of the cause which has so changed their characters, 
and who are therefore anxious to conceal from others, and desi- 
rous too to shut out from their own reflections, what they feel 
to be true, and fear to be a purely moral fault. 

And further, they who will attend to the diseases which are 
the subject of this essay, not in the usual manner, but in the 
spirit of philosophical generalization, will also often be able to 
perceive, in the general derangements of the constitution, or in 
that anomalous ill health where the term debility serves as an 
excuse and an escape for the general ignorance or the indolence 
of the practitioner as to its nature, abundant proofs of what 
ought to be considered a universal paralysis of the nervous sys- 
tem. I use the term paralysis rather than debility, because the 
analogy lies here: it is that loss of energy in all the nerves, 
possibly sometimes in the brain alone, which, in a higher de- 
gree, and more limited, produces absolute palsy; and which in 
so general an affection as I choose to select for illustration, would 
probably, in its extreme, be death. Nor is this general case, to 
which I here allude, uncommon, if it is sometimes slight, and 
from that cause therefore, among others, overlooked. It conti- 
nues often, even for weeks or months, after an acute attack of re- 
mittent or intermittent, or perhaps follows even a durable con- 
dition of the chronic variety, being frequently also attended by 
obscure symptoms of this fever itself. In such cases there is 
ordinary muscular debility, while every muscle of the body, 
even to the fingers, including also the diaphragm itself, is affect- 
ed. From this last cause it is that the respiration becomes so 
peculiarly affected, as we often find it in these cases: while in ad- 
dition to all this, the heart and the arteries act feebly and slowly, 
there is no appetite, the bowels become peculiarly torpid, and 
the senses of taste, smell, hearing, sight, and even of touch, are 



MARSH FEVER AND NEURALGIA. 399 

most perceptibly impaired; the insensibility of the eye being 
peculiarly remarked by those who have naturally perfect eyes 
and acute sight, and who were in the previous habit of making 
accurate use of them. If the mental faculties are then also fre- 
quently impaired, it is but a consequence that would be expect- 
ed: and from a few cases (not however sufficient) which I have 
seen, I am inclined to believe that when this latter effect occurs 
as the striking symptom, the others would be frequently found 
if sought for. 

And if I have thus shown that paralytic affections, local or 
general, as also idiotism or debility of intellect, are both brought 
on by intermittent diseases, whether fever or Neuralgia, and 
that it is the effect of evacuations to aggravate or determine both ? 
the action, as I shall hereafter suggest more distinctly, being ex- 
erted on different portions of the nervous system, and if also 
cold, apparently pure cold, can induce palsy, so does it operate 
on the intellectual faculties, producing the analogous effects, de- 
bility of mind, fatuity, and even mania. The analogy is valua- 
ble, as illustrating the effect of debilitating remedies in pro- 
ducing fatuity and also mania: and while the general fact seems 
to have been proved on a very large scale during Napoleon's 
Russian campaign, as it is otherwise known to have happened 
elsewhere in similar circumstances, there is one very pointed 
case in Bartholinus, where three young women, from long ex- 
posure to cold in an open carriage, became fatuous, and did not 
recover during a fortnight 

But leaving this analogy to make such impression respecting 
the subjects under discussion as it may appear to justify, I may 
proceed to remark, that if palsy and fatuity are produced by in- 
termittents, as I have formerly shown to be the fact, and also by 
neuralgia, as I have now indicated, while they are similarly 
produced by cold, and also by many poisons acting on the sys- 
tem, and while also they are the not unfrequent consequences 
of the depressing passions, all of these coincide to prove that 
diminution, exhaustion, or partial destruction of the mysterious 
nervous power, is a direct effect of intermittent and of neural- 
gia, or of the causes of these. I may now further show, that 
mania is equally, and not very rarely, the effect also of the neu- 
ralgic diseases; particularly, it would seem from experience, 
when the affected nerves are seated near the brain, or in the ex- 
ternal parts of the head. It requires but this to complete the 
entire analogy as to the corresponding action of neuralgia in pro- 
ducing disorder in the nervous system, and perhaps, correctly 
speaking, in the brain alone; since I have just said that mania 
takes place from cold, and have formerly shown, fully, that it 
is also a consequence of intermittents or of their cause. 

This fact has been already partially stated in a former chap- 



400 CONSEQUENCES OF 

ter; and although the mania was, in one case at least, the appa- 
rently decided effect of improper evacuations, it does not alter 
the argument, since, in all the analogous cases, this appears to 
coincide in power with what we must consider the fundamental 
cause, in aggravating or determining the effect. And if it is' a 
common remark, though I know not how strictly true, that 
courses of Cheltenham waters, or of purging, have actually 
produced Mania, I should not be surprised, were these cases to 
have been examples of some of the chronic diseases in question, 
mistaken for some of the disorders already pointed out. 

But independently of that, cases of Mania from hemicrania, 
clavus, headachs, all evidently neuralgias, are also recorded by 
many authors; while, when these effects are attributed by the 
narrators to the violence of the pain, it is evident in some of 
the instances, that the degree of this was not sufficient to justify 
that consequence; while, under any view, an alienation of mind 
arising from mere pain, is but a temporary delirium. On the 
principles here laid down, the explanation becomes easy; while 
the facts in question confirm those very views which make the 
mania, not a consequence of the pain, or of the mere suffering, 
but an independent and associated effect of the general neuralgic 
disease. I have here referred to the cases of authors, all of 
whom I have often had occasion to quote; and I could add par- 
ticulars, whether from such books or from living authorities, to 
a considerable extent: while from those which I know or un- 
derstand best, I must determine without hesitation, that the dis- 
order was proper and true mania, and not delirium. 

Thus then the entire analogy is rendered complete as to all 
these associated consequences; whether produced from or by 
all these disorders, or whether as arising from the other causes 
iust alluded to; while it is almost as unnecessary to insist on the 
analogy between mania and fatuity, as on that between this state 
of the nervous system and palsy; the transition of the one into 
the other being familiar, and there being other connexions, as- 
sociated with the other causes of both or the whole of these dis- 
eases, on which it would be beyond the present investigation to 
dwell in more detail. In this essay, limited as are its objects, I 
dare proceed no further in this question; but as I hinted when 
speaking formerly, of the mania of intermittent, it will be for 
physicians to inquire whether they have not too much entirely, 
I might almost say, neglected one general source of Mania, and 
whether, in looking too often for organic derangements, they 
have not even committed a leading error as to the total causes 
of this disease. With respect to the occurrence of mania under 
these circumstances, or to its connexion here with fatuity, as far 
as that relates to the proximate cause of either, it is not difficult 
to form some broad and general conceptions to justify the pos~ 



MARSH FEVER AND NEURALGIA. 401 

sibility a priori; but nothing special can be said, or even con- 
ceived, on that subject, while we continue in ignorance of the 
nature of the nervous system and the nervous power; while 
whatever else I have to offer on that subject, vague as it must 
be, will find a better place in. the last chapter of this work. 

Such is a sufficient description of these affections and their 
modes; while in the preceding descriptions, will be found some 
examples of cases to which I could, if necessary, have added 
others. Nor will the mere formal separation of these particu- 
lar diseases be without its use, if it shall excite such an in- 
creased attention to paralytic diseases in general, as to lead to 
the discrimination of these particular cases and causes; since it 
is most certain that while they are often directly produced by 
the debilitating practice in intermittent and neuralgic diseases, 
they are invariably aggravated by it. If, for example, a patient 
labouring under the apoplectic attack of intermittent be largely 
bled, as I formerly showed, he will probably either die or be- 
come paralytic permanently, or else he may be thrown into a 
state of fatuity; while if the paralytic attack of intermittent be 
treated in the same manner, that which would have been a tem- 
porary disease, passing away entirely in a day or two, or de- 
clining gradually, will become a rooted and incurable palsy. In 
the other case; should palsy supervene on neuralgia, want of 
knowledge or observation may lead to its being considered as a 
separate disease, and with the same results; since the practice 
in question is too often employed without reflection, mechani- 
cally, in all these cases, and rarely indeed omitted when the af- 
fection is extensive. 

Hence the value of these remarks and these distinctions; 
while a long experience, or rather observation of the practice 
of others, has convinced me that such cases are not uncommon, 
and that a great number of the paralytic diseases daily met with, 
have been the direct produce of the erroneous practice in ques- 
tion. How often a palsy may be the actual result of Malaria 
rather than of cold, I am not prepared even to conjecture; but 
when, among six persons, attacked within the same season, in 
the same spot, by intermittent, two were attacks of palsy, I am 
inclined to imagine that even this cause is a much more frequent 
one than it has ever yet been supposed. 

Of the cure in such cases, what I have to suggest, directly, 
may be contained in a few words; while the great caution is, to 
avoid the usual debilitating system. Nor while I offer a few 
hints on this subject, can 1 extend those beyond the case of pa- 
ralysis. If it must be always difficult to gain experience as to 
cases of fatuity, from the general conviction that they arc in- 
curable and causeless visitations, such experience as to Mania 
is unattainable, by an ordinary physician, from the received < 



402 CONSEQUENCES OP 

vision of labour in this disease; while this is a case also on whrcfe 
it may be doubted whether that division is a valuable invention,, 
I have therefore no experience as to these particular diseases; 
though ready to believe that whatever may prove beneficial in 
the paralytic ones would also be profitable here. To these last 
I must therefore limit the very few remarks which I have to 
offer. 

Wherever the system to which I have just alluded has been 
followed, I have invariably seen the cases terminate ill, while 
in every one that I have seen where nothing at all was done, 
they have recovered spontaneously; every case that I have my- 
self treated (and they have been numerous) having been cured^ 
even though the intermittent remained or reappeared. I might 
therefore say that no remedies were necessary; or that, when 
intermittent was present, we should simply attend to that dis- 
ease; though I think it expedient that purgatives, but not the 
highly debilitating ones, should be used; imagining, that, under 
a moderate practice of this kind, at least at the commencement, 
the disorder has, in my experience, terminated more rapidly. 
As far as local remedies, short of cupping or leeches, can serve 
to amuse the patient and give the appearance of acting, they are, 
of course, admissible; and thus also may we have recourse to 
those internal stimulants habitually used in ancient palsies, since 
these coincide with the general system of cure in all the diseases 
under consideration. 

Now, under the obscurity which attends all cases of direct 
and primary palsy, without previous apoplexy, and particularly 
as occurring in young subjects, I cannot avoid extending these 
remarks somewhat further, that I may be sure of embracing the 
cases for which I cannot, with certainty, assign the cause. 

If Intermittent is produced by cold as well as by Malaria, if 
Neuralgia under its many forms is much more satisfactorily 
proved to be produced in the same manner, and if Intermittent 
and Neuralgia, both, can produce palsy or be accompanied by 
it, all of these being facts proved, there may be a much more 
intimate connexion between direct primary palsy and Neuralgia 
than we are yet aware of, or the actual condition of the nerves 
under the former disease may bear some resemblance or analo- 
gy to that which exists in the latter. And the exciting cause 
also may often truly be the same, though acting here in a man- 
ner somewhat more rare than it does in general; while, as to the 
proximate cause, in any case, we are as yet most profoundly ig- 
norant. That the former is so in the instances of palsy follow- 
ing cold, is plain; and, here, it becomes truly probable that the 
proximate cause, or the morbid condition of the nerves is also* 
in the direct palsy of this nature, what it is in the palsy accom- 
panying or following intermittent and Neuralgia. 



HARSH FEVER AND NEURALGIA. t$5 

These are but analogical arguments, I am aware; but none 
better founded can be produced until we become acquainted with 
the real condition of the nerves under these diseases, or have 
mastered the proximate cause. Yet they involve a high degree 
of probability as to the real resemblance among these apparently 
'different palsies; and if that probability can be rendered a certain- 
ty, this should become a guide to the practice; since that which 
has "been found injurious in the palsy of neuralgia and intermit- 
tent, should also be injurious in every primary palsy, or the re- 
verse. And further, if a careful observation of the actual prac- 
tice and its results, shall confirm this view, then have we all the 
evidence which we have in so much more that belongs to phy- 
sic, and at least sufficient to form the basis of a rule of practice, 
until we have arrived at a more profound knowledge of the pa- 
thology of the nerves. 

I cannot here venture to treat the whole subject of palsy, as 
it would form an unjustifiable digression from the main subject: 
but I am backed by a great weight of authority from the most 
ancient times of physic, when I declare my belief that the treat- 
ment of simple palsy by the evacuant system is pernicious, and 
my further conviction that it is actually, and at the present day ? 
the cause of the diseases which it undertakes to cure: that it not 
merely aggravates and renders permanent, attacks of palsy which 
Would otherwise be transitory, but that it induces on those a va- 
riety of accessory evils; and further, that, in itself, it produces 
cases of palsy that would never have occurred; and all this with- 
out regard to the cause, or without my supposing it necessary 
that this should have been Malaria, or that the disease should in 
any way have been connected with Neuralgia or Intermittent. 

Were I here justified in going more deeply into this question, 
I might easily extend these arguments much further; and em- 
brace also the whole as it concerns apoplexy no less than palsy, 
I am as little entitled to this now, as I am unwilling to enter 
upon a criticism which would then become unavoidable, upon 
the many very loose writings, comprising even very recent ones, 
which have appeared on this subject: but I will refer to the opi- 
nions and experiments of Serres for some particulars, which, in 
spite of the opposition they have experienced, are of more real 
value on this question than any thing which has yet been writ- 
ten respecting it. 

If it is said that no competent physician would confound ;i 
palsy really requiring blood-letting with one demanding the op- 
posite treatment, this is not the question in hand, but what the 
practice actually is, when we take the entire mass of cases and 
the entire mass of practitioners. And if this be done, I believe 
it will be safe to say, that in ninety-nine cases of a hundred of 
recent palsy, blood-letting is used as the first remedy, without 



404 CONNEXION Of 

inquiry as lo the cause, or without regard to the state of the pa* 
tient, or to any one circumstance; while if the least justifica- 
tion can be found for repeating and renewing it, though that be 
a mistaken one, and often without any justification at all, it is 
repeated, together with the rest of the system, till the patient's 
state becomes hopeless or he is despatched to his grave. Most 
generally also, this is a merely empirical practice, mechanically 
followed, like so much more in physic; while if there be a the- 
ory, it is the sweeping, and most often false one, that the dis- 
ease is in the brain, and consists of effusion, or excess of action, 
or aught else which may appear to justify such practice; while 
it seems also to be forgotten that a portion of the nervous sys- 
tem can and does suffer, not only loss of power, but other dis- 
easesj independently of the brain, or independently of excess of 
action in the circulating system: as happens in paraplegia from 
partial cold, from poisons, local or otherwise, such as in the case 
of lead in both modes, or from intermittent, or as the conse- 
quence of Neuralgia. 

But I dare not pursue much further a subject which would 
lead me beyond my proper limits, while I must, however, point 
out one fact, in medical arithmetic, which seems strongly to con- 
firm what I have here said respecting the erroneous treatment of 
palsy. Its recent' increase, in point of numbers, is matter of fa- 
miliar observation; and it will be found to have commenced and 
kept pace, as nearly as that can be estimated, with the enormous 
recent increase in the frequency and severity of the evacuant 
and debilitating system; while the study of individual cases can 
leave little doubt, that the latter is the cause, when it appears a 
necessary consequence to vulgar observers, and to those who, 
following an imaginary system of cure, do not perceive that 
they are themselves the causes of the diseases which they erro- 
neously strive to remedy. 

If I could fill pages with cases illustrative of this assertion, I 
must be content with much less; because I dare not enlarge fur- 
ther on a subject that falls somewhat beyond my own boundary 
line, and because I have already pointed out instances, within 
that limit, where the bad effects in question have followed from 
that practice, in cases decidedly connected with intermittent. 

In one of those, the subject, a slender and delicate man of 
middle age, had been exposed to cold, while in a state of inac- 
tion, for so many hours, that on attempting to move, he was 
thoroughly benumbed and partially insensible. A surgeon, 
who chanced unfortunately to be present, conceived that he was 
about to suffer apoplexy, (it would be difficult to conjecture 
why,) and immediately proceeded to perform venesection. This 
was followed directly, by an imperfect hemiplegia, or an in- 
crease of the numbness and insensibility on one side; and as palsy 



MARSH FEVER AND NEURALGIA. 4.05 

must necessarily justify bleeding, the operation was repeated, 
together with all the other aids, till a complete hemiplegia was 
the consequence. More blood-letting, more cupping, and more 
of all the usual remedies of this class, brought on at length, and 
gradually, but not under a twelvemonth, epilepsy, fatuity, and 
death; each addition of the artificial debility aggravating the 
disease, while each aggravation, attributed as usual to the dis- 
ease, and not to the remedy, was followed by the more vigorous 
use of this. 

But this, in some form, is of every day occurrence: and I may 
now give a case of the reverse treatment. Under the very same 
circumstances, another person was seized with a similar attack, 
in the same manner, and in the same place, while the effect of 
cold had proceeded so much further, that the power of speech 
was nearly gone, as were the intellectual faculties. The same 
theory was offered, and the same proposal made; but the prac- 
titioner chanced to take a different view oT the cause and case, 
and this patient, by the aid of heat, and of wine given liberal- 
ly, was perfectly restored to health within twelve hours. That 
the event would have been what it was in the former case, had 
the treatment been the same, is most undoubted; but few, un- 
fortunately, whether patients or ordinary practitioners, view 
events in this manner; the former, as I once before remarked, 
giving the discerning and successful physician no credit for the 
prevention of a disease, while they reserve all the praise for him 
whose malpractice has produced or aggravated one, but whom 
kind nature has opposed in the production of absolute death; 
while the blind practitioner goes on as usual, unable to anticipate 
what might have happened, but has not, because he can see no- 
thing but what is before his eyes, and is incapable of reasoning, 
inasmuch as he has no grounds and no philosophy. Thus is it 
the daily fate of him who can foresee events because he knows 
their causes, to prophesy, like Cassandra, and, like Cassandra, 
not be credited; and, thus, in other cases, does he deprive him- 
self of all his rewards, of profit and praise alike, because, fore- 
seeing, he has also prevented. Hence also does fame follow, 
as it precedes, the Sangrados: since, under the same discerning 
philosophy, it is to him of most deaths that the most difficult 
cases have fallen, while, for them, he has of course exhausted 
all the skill of all physic. " All that could be done has been 
done:" but the angel of death is he who knows where was his 
best ally. 

To conclude, if throughout this work, I have thought it a duty 
to draw all my inferences from my own observations, consider- 
ing that thus only I could avoid being misled, or prejudiced, or 
thus at least avoid adding one more copy or compilation to the 
heap in which physic abounds, and if every authority which I 



A06 CONNEXION OF 

have here introduced was not sought for until the entire work 
was written, I am the more pleased that I can find authorities on 
any point, to confirm what had occurred to myself; while such 
a concurrence of views between different persons, all equally 
unbiassed by each other, ought, to the reader, to be an addition- 
al warranty for their truth. 

Thus, on the subject of the connexion of. palsy with Neural- 
gia, I -find numerous cases, of which, however, I need notice 
but two, as I consider it a point established. It is from Cooke 
that I quote a case of C. Bell's, where palsy with great debility 
followed what he calls an inflammation of a nerve. And in 
this case, the ulnar and fibular nerves were affected, and as it ap- 
pears from the sketch, for two years; the nerves being tender, 
or suffering from a slight pressure, while the pains were periodi- 
cal; alternating, further, between the feet and ihe hands. It is 
impossible to find a better marked case of the regular intermit- 
tent Neuralgia, even to the tenderness as I have here described 
it: while in addition to the fact of the paralytic consequences, 
for which I have chiefly quoted it, it is plain that it was not so 
considered, at least by the author from whom I borrow it: be- 
sides which, the having called it inflammation of a nerve, while 
it proves that its nature was not understood, is a circumstance 
which tends to confirm the criticism which I have here made on 
a reputed inflammation of the spinal marrow. 

In a case of Pearson's, where the Neuralgia was in the thumb, 
there was a partial palsy of the brachial muscles, with pain and 
debility of the lower extremities, attended by nearly an utter 
inability in walking. These are, all of them, symptoms which 
have been here pointed out on several occasions, as occurring 
where there was much general disease besides the local one, nor 
have I any doubt that the usual symptoms of chronic intermit- 
tent were present in this case, or that there had existed a. pre- 
vious disorder of this kind; while it is plain, from the mode of 
practice adopted, namely, by excoriation, although it proved 
■successful, that a correct view of its nature had not been formed. 

These two cases may suffice: and I have more than once said 
what I am here desirous of repeating, that while I regret the 
necessity of such criticism, I consider it most necessary; and 
the more necessary, the higher are the authorities by which such 
incorrect views have been entertained and such inefficient or 
pernicious practices recommended. It is true, that to explain 
any physician's case otherwise than as he has explained it him- 
self, can scarcely fail to be offensive, while it must needs be of- 
ten hazardous; but while, without this, I could not possibly en- 
force what I have here held out, to those who have not as yet 
made up their minds as to these diseases, or who have yet to 
learn? it is also important that obscure cases should, as far as 



MARSH FEVER AND NEURALGIA. 407 

possible, be removed from the class of mysteries, and reduced 
under the principles to which they belong. 

This explanation will, I trust, be received as an apology by 
those whom it may interest; and I therefore shall not scruple to 
add, that when, by one writer of note, blisters and vesicating li- 
niments are recommended in these cases, the disease has not 
been understood; and that when another of no less name recom- 
mends leeches, cathartics, the local application of laudanum,, 
opium, and colchicum, going a round of experimental remedies, 
it is a proof that he had formed, not simply an incorrect opi- 
nion, but no definite opinion at all of the nature of this pecu- 
euliar variety, nor, I may add, of Neuralgia in any form. And 
whatever exceptions there may be, unknown to me, this criti- 
cism, as far as I do read or converse, includes the profession at 
large; while, when I perceive in Swan, Heberden, and others,, 
occasional instances of a correct treatment, it is still without cor- 
responding views, as is proved by the vacillation of the prac- 
tice: by changing from the useful remedies to those of a directly 
opposite nature, or, not unfrequently, by a general traversing of 
the whole pharmacopoeia. If Hill has used arsenic, as others 
have recommended iron, it i3 just as Heberden included bark 
among his attempts on this disease. 

And let me remark in justification of this criticism, that while 
1 have here proved these remedies to have been used empirical- 
ly, no confidence can ever be reposed as to the adoption and ap- 
plication of any empirical remedy, though it should even be a 
proper one, until the principles to which it should be affiliated 
have been explained. It is the fate of such expedients to be 
abandoned as they have been adopted, under casual disappoint- 
ment: and it is therefore only when we know what their prin- 
ciples of action really are, that we are induced seriousty to trust 
to them, to persevere in them, to modify their application, or,, 
after failures which we can often thus learn to explain, to re- 
turn to them again. It is true that we do not know how the 
tonic remedies, as they are called, act, even in the case of inter- 
mittent: but we have learned by experience that they are the 
remedies, and we have also learned how to apply them and mo- 
dify their use, which is nearly all that we know of any reme- 
dies in any disease. The object is therefore attained as far as it 
can be, when Neuralgia has, on this ground, been associated to 
intermittent: and thus, even had the true remedies been always 
adopted in an empirical manner, which is far indeed from having 
been the fact, a great gain would have been effected by removing 
them and associating them in the manner I have here attempted. 

Such is the criticism which I considered an inevitable duty; 
and I have purposely avoided naming individual authors as far 
as this could be done. I will not therefore quote further « , 



408 CURE OF NEURALGIA. 

or further opinions; that I may as far as possible escape this dis- 
agreeable task; but shall refer those who desire to see what has 
been done and thought on this entire subject of Neuralgia, to 
Heberden, Pujol, Sauvages, Fothergill, Hutchinson, Bew, Li- 
zars, Carlisle, Ash, Hill, as to others whom I have been obliged 
to quote more pointedly, and to many more whom I need not 
here name. 



CHAPTER XXI. 



On the Cure of JVeuralgia in general. 

If I am right in my theory of Neuralgia, if it is a disease? 
under whatever form it occurs, depending on a constitutional 
cause or derangement, though the prominent symptoms are lo- 
cal, and if it be a mode of intermittent fever, or, fundamentally 
of the same nature, it might have been anticipated that I should 
have recommended the same system of cure, even had I not al- 
ready been compelled, in treating some of its varieties, to enter 
partially on that subject. On this view, in fact, was founded, 
far more than twenty years ago, the system of practice which I 
applied to these disorders; or it was a theoretical mode of cure, 
derived from that theory of the disease in general which I then 
thought the true one, and which a continuous observation, ever 
since that time, has tended to confirm. And if the theory has 
been thus confirmed, so have the correctness and utility of the 
practice; as it has never failed me in any case of recent origin or 
moderate duration, as it has even succeeded in numerous in- 
stances of very long standing, and in many at the same time, 
which I had received from other practitioners as incurable dis- 
eases; failing only in those inveterately chronic cases, analogous 
to the simple intermittents of this same character in which the 
same remedies equally fail; and further, being chiefly unsuccess- 
ful, possibly, when the visceral glands have been hopelessly dis- 
eased. 

Though I cannot well avoid detailing the modes of cure in 
this separate section, since the omission would leave a blank to 
many medical, and to all popular readers, should such there be, 
it is plain that I must do it under considerable repetition; since 
much of the detail must resemble what has already been said on 
that subject h\ the case of intermittent And also, as under 



CURE OF NEURALGIA, 409 

Some of the varieties that have been described, I could not 
avoid entering partially on Ihe subject of the cure, on account 
of certain peculiarities attending those, and because a general 
account of the mode of cure would have been confused by those 
particular details, I must claim the indulgence of the reader for 
what must be considered a blemish in every composition pre- 
tending to philosophy. It must form my apology for this, as 
for all defects of arrangement and all prolongation, that my task 
was a very complicated one; since it has not consisted in a mere 
description of acknowledged diseases, but in a complicated at- 
tempt to establish, to prove, and to describe, and further, to pull 
down, not one building but a variety of Old ones, and on their 
ruins and from their pajieriajs, to erect a totally new structure, 
and one as single and simple as it is new. 

Jn treating of this subject, I must equally, as on former oc- 
casions, take notice of what I consider to be wrong in the past 
an^ the present practice, while 1 describe what i conceive to be 
right; becoming thus again a compelled critic, as must be every 
one who, in attempting reform, must oppose prevailing or gene- 
ral opinion. And if it is always necessary to combat most 
strongly where the opposed authority is the most powerful, no 
where can this be more necessary than where that authority 
consists in universal opinion. It is, still, an odious office; but I 
know not who ever succeeded in steering exactly between that 
criticism of imputed error which the opposed party brands with 
the term acrimony or worse, and that timid' ty of over caution 
which defeats the object in view; leaving the truth, if truth it 
be, to quail and fly before the enemy to which it shows a mis- 
placed tenderness. Where no offence is intended, it is a weak 
fcimiditjr that fears lest it should be taken; as it is a vicious one 
which suppresses what it deems useful, from personal apprehen- 
sion or a cowardly love of peace. 

The first remark which I must here make repecting the Cure 
of all the Neuralgia, though already made more than once, is 
that they often disappear without medicines, and even without 
apparent remedies of any kind, by a spontaneous action of the 
constitution; while they are also truly cured by circumstances 
that are not noticed, and to which the credit is not given. And 
it is an important remark; because it often explains the reputa- 
tion which has been gained by particular modes of cure, which 
have been, in reality, either nugatory or injurious in themselves. 
And thus it is that improper practices are persevered in ho v. 
mistaken observation: a conclusion which I mighl apply in great 
detail to every mode of Neuralgia, and also, as I have in fact, 
already done, to Intermittent. 

If these spontaneous cures are most frequent in a recent dis- 
ease, they are not uncommon even in the most confirmed ones; 



04 



410 CURE OP NEURALGIA. 

and they seem, in these latter cases, connected with that entire 
change in the constitution, at some age, often vulgarly called 
climacteric, which is marked by many other well known cir- 
cumstances, and, in females, by one too familiar to name. Thus 
it is that in this sex, very remarkably, the nervous diseases of 
many previous years vanish at this time; as, under this particu- 
lar head, thetoothach will very generally be found to do; as well 
as that tendency to the frequent petty or nervous fevers which 
belong to remittent or intermittent, and much more that I need 
not detail. 

In both forms, whether recent or chronic, neuralgias of all 
kinds cease also on the occurrence of some other principal dis- 
ease, as equally happens in intermittent: though perhaps the 
most frequent of the real, but litie observed causes of a cure? 
will be found in change of air, as it is called, or a general change 
of habits. And, this, in fact, is a direct remedy of great pow- 
er? while it is amusing to remark how often it is actually used, 
when the practitioner himself has not so intended it, when he 
has applied to it from despair or weariness, or that he might rid 
himself of a patient's reproaches, or when, mistaking the nature 
of the disease, he has resorted, either blindly, or for some other 
purpose, to such an expedient. 

Thus also are all the neuralgias, and the recent ones in parti- 
cular, occasionally cured by mental impressions, as I have shown 
with respect to intermittent generally; and numerous and pow- 
erful as these are, peculiarly extensive as they sometimes prove 
in our own country, from well-known causes depending on the 
condition of England, they must be considered as amongst the 
most frequent of the unobserved modes of cure, causing a great 
extent of error with respect to the operation of presumed re- 
medies. And amongst these, if apparently trivial, must be 
ranked a cause often no less efficacious than it has been made a 
subject of ridicule, namely a change of physicians, or the acqui- 
sition of a new and strong confidence in a new and reputed per- 
son. Hence an actual benefit often derived from empirical re- 
medies and empirics, or from physicians of popular, if false re- 
putation, or of peculiar, perhaps insolent or coarse manners: an 
influence extending widely over all the nervous disorders, of 
which so many occur from the general cause of disease which 
includes the subjects of this essay. 

This in reality is the cure by charms; but in the present state 
of society there is little chance of benefit by direct methods of 
this kind. Physic however does furnish even these means; as 
there is scarcely an individual existing, even of the most en- 
lightened mind and liberal education, who can view medicines 
as acting according to scientific and rational principles, and who 
does not, in reality, place that kind of confidence in their pow- 



CURE OP NEURALGIA. 411 

t,vs which marks the belief of the early and uncivilized stages 
of society; viewing them as mysterious agents, almost as incan- 
tations, however he may disclaim the opinion when thus dis- 
sected and presented to him. Hence that universal confidence 
In substances and formulae and numbers and quantity, and hence 
especially that enormous consumption of Empirical remedies; 
compounds found in every pharmacopoeia, but divested of all 
their virtues under this form, because separated from the mys- 
tery and the incantation. The physician who attempts to rea- 
son with his patient on the effects and utility of his remedies, 
pays a most unmerited compliment to human reason: and while 
he will fail to influence, he will not be very long in discovering 
that he will shortly have no patients to enlighten or to cure. 
With the loss of the mystery, 5 the merit is at an end: and he 
who proves himself to be the true philosopher and physician, is 
precisely the man who will never be trusted. 

If medicines, even be they bread pills duly concealed, form 
a mode of cure in the Neuralgia, as charms, the same effects 
are produced by any other folly or superstition to which fashion 
may have given its sanction among the foolish and the supersti- 
tious. Hence the real, not fictitious effects of animal magnetism, 
metallic tractors, and the like; and thus it is, that an appended 
magnet does truly cure the toothach; this being the Neuralgia 
of all others which is subject to be transitory, or not firmly 
fixed in the habit; just as it is frequently removed by the sight 
of the instrument or the operator, as I formerly remarked. And 
how efficacious a system of charming, when believed in, is, I 
once witnessed amply, in an old woman who had this reputation, 
and whose success among the lower orders Was very great; 
while I wjs induced by curiosity to send her a case of Neural- 
gia (Tic) which I had, for some length of time, treated in vain 
with arsenic, and which ceased immediately after the application 
of the charm, consisting in some gibberish. 

How far such modes of cure can be adopted and rendered ap- 
plicable to patients, must be left to the ingenuity and observa- 
tion of practitioners. If of little real value, it was not the less 
necessary to point them out, as explaining in a great degree the 
false reputation acquired by many medicines. 

As happens in intermittent, a fit of Neuralgia is often pre- 
vented by stimulants and narcotics given before the paroxysm: 
and, on the same principle that the disease itself is cured in the 
former cases, that is, by breaking the habit of recurrence, may 
the entire Neuralgia also be removed. I need not specify, ci- 
ther the substances or the mode of administration, since this was 
sufficiently explained in treating of the cure of Intermittent on 
this principle: but it is an auxiliary at least, if no more, that 
ought not to be neglected wherever a reasonable prospect o( uti- 



412 CtTRE OF NEURALGIA. 

lity appears. This partly explains the effect of Intoxication in 
removing such disorders: though as that, will act advantageous- 
ly at whatever time it happens Go be. adopted, it is probable that 
it operates by exciting another action, or a temporary artificial 
disease, in the system. 

I conjecture that we must thus a^so explain the action of the 
narcotics, which have been so strongly recommended in Neu- 
ralgia, and administered in such an outrageous manner. They 
are not, however, the real remedies of this disease in any of its 
forms; while, as administered to diminish the pain, they are of 
very small value. Whoever has trusted to them much, will 
know from his own experience that I advance here nothing but 
the truth; while I have myself received from other practition- 
ers, many cases where they had been pushed to even a dange- 
rous extent, without the slightest advantage, and where the dis- 
ease was speedily cured afterwards by a proper administration 
of bark. It is abundantly obvious that they have been recom- 
mended and adopted without a correct view, or any view at all, 
of the theory or nature of this class of diseases: empirical re- 
medies against a symptom, according to the usual mechanical 
practice of physic; means of quelling pain, without inquiring 
from what that pain proceeded. 

And on the same empirical system 3 the whole army of these 
poisons has been mustered, from opium to belladonna; while an 
occasional success, from some of the causes already stated, has 
been made the ground of a general recommendation. I am even 
suspicious that they have done harm; having seen one case of 
mania immediately following their extravagant use in the Tic, 
and in a patient who could not have been suspected in the most 
remote degree, of such a previous tendency; while the entire 
freedom from that disease for thirty years, through the whole 
of life in fact, after a duration of two months, confirmed this 
opinion. Nevertheless, that the narcotics were the exciting 
cause, is little more than a suspicion; inasmuch as mania is the 
produce of the disease itself, though probably not unless aided 
by improper treatment, and particularly by the evacuant sys- 
tem. 

But the chief and the most energetic remedies in Neuralgia, 
be the form what it may, are the tonics; and of these, as in in- 
termittent, the most efficacious are bark and arsenic. Each, in 
its class, may stand at the head of a list which it is fruitless to 
enumerate, since it is so well known to even every druggist; nor 
need I repeat what relates to the mode of using these, since it 
is precisely the same as in intermittent fever. That there is any 
one vegetable tonic more efficacious than bark, or differing in 
the mode of action, as far as we now know these remedies and 
their powers, I am inclined to doubt, but not to deny that such- 



CURE OF NEURALGIA. 413 

do exist, since I consider that we are very far from having ex- 
hausted the medicines of the vegetable kingdom; so far indeed, 
as rather to be in an absolute infancy of knowledge on this sub- 
ject. 

If modern physio has done wisely in rejecting the endless 
and useless list of the plants found in ancient pharmacopoeias, it 
has shown very little wisdom in resting nearly content with 
what it has retained; particularly in an age when the great ex- 
tension of experimental and accurate philosophy, and the abso- 
lute creation, we may almost call it of a new chemistry, added to 
which, I might say, the almost further creation of a particular 
branch of this as to vegetables, have furnished means of accu- 
rate investigation, formerly unknown as unsuspected. The very- 
fact that a plant so void of obviously sensible qualities as Digi- 
talis, should possess the extraordinary, if yet almost useless 
powers which it does, ought to be in itself a sufficient stimulus 
to investigations of this nature; a temptation too, much in- 
creased hy the recent facts which chemistry has proved and is 
daily augmenting, respecting the infinite variety of radical or 
essential compounds or bases. 

To return; while, with bark as the type, the physician may 
command the whole range of astringents, aromatics, and bitters, 
he is also bound to try one where another fails; since thus may 
it possibly be discovercl, even that what is most efficacious in 
common intermittent may not be most so in the Neuralgias, dif- 
fering as they do in respect to. the local action in the latter. But 
as I can, on this, say nothing of any great value from my own 
experience, I must be satisfied with having pointed out the lead- 
ing principle and the road to be followed; as I need also do no 
more than suggest those combinations, whether of these vege- 
table substances themselves, or of the same with narcotics, the 
occasionally superior value of which in intermittent is well 
known. 

If arsenic be admitted as the type of the metallic remedies, 
it is equally easy for the physician to command the whole rano-e 
of these: so well known, that I could add nothing respecting 
their powers; while I much suspect that very fanciful values 
have often been attached to some of them, from that common 
mechanical system which looks more to variety of medicines 
than to a knowledge of diseases. Much has indeed been lately 
said respecting the especial value of the carbonate of iron (as it 
is generally called) in the common Neuralgia (Tic;) while in re- 
ality it has been administered as a merely empirical remedy, 
and without system. In my own experience, I had resorted to 
it long before these recommendations, both in intermittent and 
Neuralgia; but without discovering that it possessed any colla- 
teral merit above arsenic, while far less generallv efficacious as 



414 CURE OF NEURAL&IA. 

a remedy. But, on all these remedies, I shall be very glad to 
hear of the experience of others, since I have wanted both ictrp- 
tation and opportunity to do them justice. As to the value of 
arsenic compared to bark, I can only repeat what I said former- 
ly, that I have found it more generally efficacious in Neuralgia, 
while it has appeared less so in intermittent: often acting almost 
like a charm on the pain, and even in cases of many years' du- 
ration. But on this also I am ready to be corrected; as I am 
satisfied that the experience of no one individual, even were it 
far greater than mine has been, is sufficient to decide on subjects 
of this nature. 

If I have thus said all that appears necessary on what I con- 
sider the essentia) or fundamental remedies of Neuralgia, I must 
also add that I make no distinction as to the forms of the disease; 
except that I must hesitate as to sciatica, from want of sufficient 
experience in that variety. I should here however repeat, what 
I ought not to omit in this place, that from a medical friend re- 
siding in a district where this dissase is common, or endemic, 
to whom I h?id recommended this plan, i have received the 
strongest testimony, (added to thanks,) of the value of arsenic. 
In every other form, the success has been similar, and, it? every 
case of moderate duration, satisfactory; though 'ass so, as I 
shall presently show, in ancient cases, Thus, whether it be the 
Tic, or the similar neuralgic pain of other distant nerves, or the 
hemicrania, or the toothach, or the rheumatism of the face, or 
the rheumatic ophthalmia, the use and efficacy of these reme- 
dies is the same, with such additions respecting particular cases, 
as I have already passed under review in their proper places. 
And it is also the same, as I formerly remarked, even when the 
Neuralgia is the produce of local injury. 

But I must now remark, that there are two leading circum- 
stances under which they very often disappoint us, ar:d where, 
unfortunately, as in the case of intermittent similarly modified, 
physic has as yet discovered no expedient to supply their place, 
while I have none to offer. 

This happens, first, when the attacks of the disease are very 
irregular, and secondly, when the disorder is of very long stand- 
ing; while, in exact correspondence to intermittent, these two 
states are very commonly united. But if we often fail in such 
eases, we are not absolutely without some means of attempting 
relief, and those attempts are often also successful. 

In irregular or ill marked intermittent, when recent, or not 
of very long standing, and particularly if other circumstances 
justify it, a single blood-letting will sometimes render the type 
regular, as I formerly remarked; and thus, though I have no ex- 
perience to prove it, I should not hesitate to make the same at- 
tempt in a Neuralgia, under the same circumstances, though con- 



CURE OF NEURALGIA, 415 

vinced of the infinite evil of this system when persisted in. 
The same effect will sometimes also be produced by an emetic, 
but perhaps much more frequently and advantageously by pur- 
gatives, and especially by calomel; while, as a mere speculation, 
it is always advisable to have recourse to such medicines, as a 
preliminary to the administration of arsenic or bark. 

Thus also does mercury, given so as to affect the constitution, 
in Neuralgia or in intermittent, sometimes cause these tonic re- 
medies, to be efficacious when they have failed before; while it 
is also, in itself, an occasional cure. It is possible, that, in this 
last case, its useful action may resemble that of the other metal- 
lic substances, whatever that action, called tonic be; while, ap- 
parently, also, it acts here as in intermittent, in exciting another 
disease, or a new action in the system. Whether, in the for- 
mer case, or in the latter, it acts by affecting advantageously 
diseased visceral glands, is a. question which I cannot answer; 
while if I do not disbelieve it, neither am I willing to believe 
what has not been demonstrated, and which is not proved be- 
cause it is popularly believed, like much more in the lax philo- 
sophy of physic. But be the theory what it may, a judicious 
physician will, without further detail, see in what cases, in what 
mode, and to what extent he may resort to mercury in the Neu- 
ralgias, and in what manner he may unite its use to that of the 
essential remedies. 

But it is in the Neuralgia when inveterately chronic that we 
are most often foiled; and as, unfortunately, the greater number 
of cases which apply for relief must now be of this nature, from 
that want of success hitherto, arising from a deficient method of 
cure, which has rendered the majority of cases chronic ones, 
and perhaps still more from a pernicious system of treatment 
which has confirmed many so as to render them truly incurable> 
the consequence has been to throw a doubt on the value of the 
remedies here recommended. It is plain therefore, that, if we 
take cases arithmetically, these remedies cannot have a fair trial; 
nor will this happen until many years have passed; until the in- 
curable, long standing cases have died away, and a new genera- 
tion of the same diseases shall arise under a new practice. I 
shall be much mistaken, though I shall not live to see it, if Neu- 
ralgia will not then be found a tractable disease compared to 
what It has hitherto been; or even than it would be now, were 
the most correci imaginable practice adopted to-morrow; that it 
will at least produce no greater average of rebellious cases than 
Intermittent, though, even then, the world at large will be deep- 
ly indebted to him who shall discover the means of alleviating 
these curses, or rather, these varieties of one wide and deep 
curse. 
But there is yet another reason, which, while it tends greatly 



416 CURE OF NEURALGIA. 

to render Neuralgia chronic and incurable, will long be an ob- 
struction to a fair judgment on the value of these remedies; as 
long at least as 1 ill they shall become universally empirical, like 
medicine in general; if indeed we can ever look with satisfaction 
to empirical medicine. This is the ehangeableness, or the ca- 
price, of patients, or their impatience. Anxious, very natural- 
ly, for a speedy cure, but without discern ment to choose, and 
without reason to be convinced, led away in succession by name 
after name and recommendation after recommendation, the re- 
sult is that no steady system is pursued, that the work, perhaps 
half done by one, is reversed by the next; and that even he who 
could effect the object, were he granted time and confidence in 
what demands both, is foiled, and perhaps even induced to doubt 
the value of the means which he has not been allowed fairly to 
use. It is the chronic disease especially, be it this or any other, 
which, above all, demands one continuous physician and sys- 
tem; while, by aa unlucky perversion of reasoning, unlucky 
however for themselves alone, since to the profession at large it 
is a profitable one, it is exactly the situation in which the sick 
forget their own interests, to change from physician to phy- 
sician. 

To proceed. In such inveterate cases especially, but in all, 
in fact, the first fundamental proceeding should be to examine 
the habitation or situation of the patient, and to remove him 
from the causes, if causes ba present. Here it is, that z critical 
knowledge of the laws of Malaria, and a nice discernment as to 
ground, or soils, becomes of the highest importance; and here 
then we see, as in Intermittent, how a careful study and an ac- 
curate knowledge of what forms the first part of ibis Essay, is 
indispensable to every practitioner in medicine; while patients 
at least may grieve to reflect how utterly the fact is otherwise. 

Without such removal from the exciting causes, a permanent 
cure in such cases is almost hopeless; while he who knows how 
to perform his duty and does perform it, will equally take care 
to explain to the patient what he is to avoid in a new residence 
or in travel: labouring to impress him, if I may use a term al- 
most ludicrous, with an absolute hydrophobia. 

This alone may be the cure; while it is also plain that as far 
as change of air or habits is a remedy, it will operate in two 
ways. And therefore, in any case, though the actual situation 
be free of suspicion, it is to such change of place or air that we 
must trust as the leading remedy; a remedy in reality which suc- 
ceeds often, after every thing else has failed, here and in the chro- 
nic intermittent equally. And as far as there is a choice of air 
or place, that change should evidently be to a dry soil and a 
free air; yet not to a void one, since cold is in itself a renewing 
cause. Hence the obvious additional caution respecting expo- 



CURE OF NEURALGIA. 417 

sure to cold, especially to night air, dews, east winds, and so 
forth; while I have no doubt, and from sufficient experience, 
that the far greater number of the habitual cases of Neuralgia 
are rendered such by the continued application or frequent re- 
petition of the original causes; each attack being a new disease, 
in a certain sense, in a susceptible habit: facts which show most 
strongly the necessity of a correct theory, as they bespeak past 
inattention and ignorance. On the necessity of warm clothing 
in aid of this, it would be superfluous to dwell. 

Before I quit this subject, change of air, I must introduce a 
fact of some importance, although somewhat out of place, since 
it relates to fever and not to Neuralgia: the apology being that I 
was not in possession of the information when that volume was 
printed. From the judgment which I am compelled to form on 
the materials furnished, the case of Alicante, in- 1811 and 1812, 
offers an example of peculiar value as to the advantages of re- 
moval in the case of such endemics; whenever at least, a govern- 
ment possesses sufficient powers in sanitary police. In this case 
indeed, the proceeding was itself founded in error, as the fever 
was judged contagious; but I cannot yield my opinion even to 
that of the Physician Lanuza, any more than to the popular one. 
The error is too general to be remarkable: but the facts furnished 
me by the inspector of health, Morillo, himself employed in 
the cordon of exclusion, are unanswerable. It is true that the 
fever ceased on removing the sick to the country; but not one 
instance occurred of the disorder having been communicated 
personally, while this much-discussed fever was then limited, 
and always has been so, to one portion of the sea coast, and 
while further it has always occurred in the season, as well as in 
the place, of remittent fevers, and in no other. The contagious 
imported fever of Gibraltar, joined to vulgar opinion, appears 
to have misled the public at large on this subject; bat if my own 
opinion be correct, as I esteem it, it is peculiarly important to 
remark that an endemic remittent may exist within a town in 
such a manner as to deceive, from the numbers affected and 
other causes, just as it has so often produced similar deceptions 
in ships, and that in such cases it will be as effectually checked 
by removal to a salubrious spot as if it had been a contagious 
one, though on different principles. To return from this slight, 
and not absolute digression. 

Supposing all these preliminary cautions taken, the rational 
object, as to medicines, is, to attempt the cure of the attack by 
all the means already described, as soon as it i and as 

often as it returns. Like intermittent, it is a disease of habit: 
and by a perpetual interruption of that habit, it must ne met. 
And here it is, that the interest of the patient is also especially 
concerned in placing his confidence in some one individual: 

53 



4 IS CU11E OF NEURALGIA. 

giving him the charge with the means, and not arguing, asusua^ 
that the disorder returns because he knows not how to cure it. 

What remains as to the general treatment, relates to diet, 
As in intermittent, whether recent or chronic, I have no hesita- 
tion in saying that the usual full diet of persons in health, with 
a rational use of wine, forms an essential aid to the cure; and 
that it has often proved a cure in itself, when used as replacing 
the opposite and pernicious system. But I shall not enlarge on 
this; as the evils arising from low diet are involved in those be- 
longing to the debilitating practice on which, even after all that 
I have said, I must offer some additional remarks hereafter. 

It still remains to notice the local remedies which have been 
thought of use in the Neuralgias; though in speaking of these, I 
may now omit what concerns this ophthalmia, and the toothach 
in its several forms. 

Attempts, proceeding as usual on no principle but the vague 
one of relieving pain, have been made to remove that of Neu- 
ralgia, whenever occurring, by the application of stimulant and 
narcotic substances: a long list too well known to require enu- 
meration. As resorted tc for headachs and rheumatism of the 
face, the use of camphor, opium, alcohol, ether, essential oils, 
and so forth, are peculiarly familiar; and similar practices are 
scarcely less so in sciatica. In the slenderer cases or attacks, 
this kind of practice does occasionally give temporary relief, 
but without doing more; but it is fruitless to expect advantages 
from it in decided cases, or severe affections of this nature, be 
they what they may; while, to hope for a permanent cure in 
this manner, otherwise than casually, and through the influence 
of the imagination, is little less than childish. Nevertheless, as 
no inconvenience can arise from these remedies, beyond the 
trouble and expense, and as they serve for occupation both to 
physician and patient, they may be permitted to take their turn 
as usual, provided they do not supersede what is more essential. 

As I formerly observed, however, I cannot speak in the same 
accommodating language respecting blisters, though distinctions 
are here necessary. I have never yet seen a case where, if the 
blister was applied near to the disordered nerve, the pain was 
not aggravated: at least this happens remarkably with regard to 
the general pain which appears to have its seat in the ultimate 
ramifications, and, consequently, to be in the skin. Such also, 
I have since found, was the experience of Heberden: though 
whatever may be the merit of his essay, it is plain, as I for- 
merly remarked, that he had formed no theory of the disease, 
and that his practice, even when he succeeded in curing it by 
bark, was purely tentative and empirical. And very often, 
where that particular pain was not present before, it is induced 
by those applications; while, in the other cases, the extent, as 



CURE OF NEURALGIA. 419 

Weil as the severity, is often increased in an extraordinary man- 
ner, particularly should the application be extensive or persisted 
in. What is called a perpetual blister, is almost always a posi- 
tive aggravation, not only of the local disease itself, but of the 
general irritability and disorder of the system, which are often 
sufficiently severe in themselves. But I can understand how 
blistering, particularly if severe, applied to a somewhat distant 
part, may sometimes relieve the Neuralgia, on the principles al- 
ready laid down of exciting a counter impression, or a new dis- 
ease: an effect indeed that may even follow where this remedy 
has been applied on the part itself. Such is the explanation of 
Pearson's case, where a severe disease of this nature was cured, 
yet, not till after much time and very violent treatment, by the 
use of rubefacient, or rather excoriating applications; while I 
may remark on this case, as I have done respecting Heberden, 
that the practice was similarly tentative, and that no theory of 
the disease had been formed. Such seems the method of ana- 
lyzing and estimating the use and action of this class of appli- 
cations; and it will remain for physicians to judge how far they 
will continue to make use of it in particular cases, as an aid how- 
ever, rather than as a means of cure. 

What I have said on this subject is equally applicable to issues 
and setons, with such modification as the obvious differences 
may here render necessary. It will be easy to see where the 
local disease thus artificially produced, will increase the local 
evil: while it will be not less so to judge of the bad effects of 
seton6, particularly if active, on that principle already laid down, 
which condemns, in all these disorders, the adoption of eva- 
cuating and debilitating proceedings. On this and the last sub- 
ject, I might have made the application particularly to sciatica; 
but having less experience in this particular modification than I 
think necessary to allow me to speak respecting its peculiarities, 
I shall only request of physicians that they will review their 
own experience and practice in it; taking care that they do not 
mislead themselves respecting the imaginary effects of their re- 
medies; so common a source of error in all the Neuralgias. The 
great points to be kept in view respecting all these local appli- 
cations, are these; that the disease is a general or constitutional 
one fundamentally, not purely a local one, and that the local af- 
fection is not one of the circulating system, to be eradicated, as 
certain inflammations are, by a counteraction, or by exciting a 
diverting action in the neighbouring vessels. To act here on 
this principle, is to pursue that mechanical and unreflecting sys- 
tem of practice which I have so often condemned. 

Hopes have been entertained respecting the utility of eleo * 
tricity and galvanism; not unnaturally, however empirical the | 
views, It might indeed, even on a more correct theory of the 



420 CURE OP NEURALGIA. 

disorder, be almost expected that the electric shock at least, act- 
ing so distinctly on a nerve, and capable of being directed very 
near to a diseased one, if not exactly through it, might have the 
power of really changing its disordered action; but while my 
own attempts, pursued on a very great scale for very man)* years 
.in a military hospital, and for the direct purpose of ascertaining 
the value of this remedy, have had no success whatever, I can- 
not find that others have been more fortunate; though I can easi- 
ly imagine that such a disease might thus be cured through the 
influence of the imagination. As to the Galvanic electricity, 
the impression is comparatively too trifling to permit us to be- 
lieve that it can be of any value; and the same remark applies 
to the gentler electrical operations. 

The only local remedy from which I have really seen such 
advantageous effects as to induce me to recommend it, is the ap- 
plication of steam directed by the usual means of a pipe, to the 
affected part; while of course, the same reasoning applies, if in 
a minor degree, to fomentations and hot water. The value of 
these latter applications, indeed, in rheumatism of the face, in 
the rheumatic or neuralgic ophthalmia, and in sciatica, has long 
been known; if, from their too great simplicity, and their not 
being " made up in the apothecary's shop," they are less valued 
than they deserve. But while I consider the blast of steam as 
the most effective of all the modifications of this practice, I 
have often succeeded by means of it, in removing, almost in- 
stantaneously', a paroxysm of the severest Neuralgia of the face, 
and, occasionally, so as to put a stop, in the chronic disease, to 
an entire relapse, which, from all the patient's past experience, 
was expected to last some weeks. Should trys success be con- 
firmed by the trials of others, it will therefore become an aux- 
iliary at least of some value; while I have already attempted to 
impress on my readers the necessity of meeting the attacks on 
all occasions, for the purpose of breaking through the habit in 
that which, like chronic intermittent, is often a disease of pure 
habit. 

But even where this application does not remove the proper 
neuralgic pain, it is still a valuable auxiliary; and as far as the 
particular purpose here in view is to be served, I know not that 
it has ever failed me. In many cases, as I have often already 
remarked, there is a diffused and general pain, distinct from that 
of the nerve itself, arising from an affection of the minute ra- 
mifications, as there are pains also propagated, at times, along 
the communicating greater branches. And further, in very se- 
vere fits of Neuralgia, it almost always happens that a general 
soreness, or tenderness, or even pain of the neighbouring parts, 
remains long after the greater pain has ceased; considerably dis- 
tressing, and particularly to those whose entire system has be- 



CURE OP NEURALGIA. 421 

come irritable from a long continued or a severe disease. Here 
" the utility of warm water or steam, as circumstances may dic- 
tate or allow, is considerable; generally removing all these sub- 
sequent pains in a short time, and bringing on a general tran- 
quillity of the system. Thus should I expect that this remedy- 
alone would remove those slighter cases, or fits, which I have 
described in treating of these disorders formerly, in which no 
important nerve is acutely pained; but in these I have, however, 
little experience, since a physician, especially, is generally de- 
prived, in consequence of the present division of practice, of 
the power of studying, or prescribing for, diseases of a slight 
character. 

I need not apply this reasoning to particular cases, such as 
headachs, sciatica, or what not; as this would be to treat my 
readers like empirics, who must have a specific direction for 
every symptom of every disorder. He who understands the 
general theory of the disease, and of the remedies also, can ne- 
ver be at a loss; and this, in truth, while it is the only real 
knowledge, is all that a writer can well attempt to inculcate. 
I may however go on to observe, as it may make more impres- 
sion here, and as I did not dwell on it formerly, that the same 
practice, extending of course, to the entire warm bath where 
that may be necessary, is valuable in all the intermittents with 
anomalous symptoms, though 1 need not now enter into more 
minute particulars. And here also, I may point out or repeat 
the necessity of keeping warm and well clothed, the particular 
part affected with Neuralgia; not merely as a relief to the pain 
when present, but to guard against the local impression of cold, 
which not only aggravates it, but tends to bring on new attacks. 
On this subject I may further remark, as I suggested under oph- 
thalmia, that while ice has been recommended for diminishing 
the pains of Neuralgia, I have invariably seen that its first effect 
was followed by a considerable aggravation of the pain, and 
that I consider cold, in this or in any other form to be decidedly 
injurious; though it is easy to understand how, like any other 
application producing a sudden and powerful impression, it 
might remove a fit. 

Though I have already spoken of the use of narcotics, this is 
a more convenient place to point out one advantage to be de- 
rived from them; a fact which 1 purposely postponed, on ac- 
count of its connexion with the useful effects of hot water and 
steam. As a means of diminishing pain during the painful state, 
they are nearly useless, unless pushed to such an excess as to 
stupify the patient; in which case, it is probable, as 1 already 
insinuated, that their effects are injurious, while it is easy to com- 
prehend how they ought to be so, by inducing, indirectly, that 
debility which so prolongs and aggravates all the Neural: 



422 CURE OF NEURALGIA. 

But when the acute state is past, they become useful, as tending 
to remove that soreness which remains after the chief pain has 
ceased, and also by reducing the general irritation which has 
been excited by it. Thus also they sometimes act usefully, even 
as local applications, at least to sensible parts; and it is probably 
on this principle chiefly, that they are of advantage in the neu- 
ralgic inflammation of the eye. 

This comprises all that I had to say respecting the useful re- 
medies in Neuralgia; and I must now proceed to inquire of those 
practices which I consider to be injurious, as far at least as I 
have not already done so, and which, if I am right, is most ne- 
cessary to explain, that they may if possible be abolished and 
cease, 

I do not know if any one still continues to recommend the 
division of the nerve in the Neuralgia (Tic) of the face; but if 
so, it is at least not very long since it has been abandoned. I 
have quoted this operation already, as a proof of the utter igno- 
rance respecting the nature of this particular variety; as I have 
given proofs enough of the same ignorance respecting almost 
every variety of this disease at large. Surely, had it even been 
imagined that there was a resemblance between that particular 
neuralgia and sciatica, such a project would scarcely have been 
adopted as a means of cure; as no man would have dreamed of 
curing; sciatica by the division of the nerve, even had the pecu- 
liar nature of this nerve admitted of such an expedient without 
another obvious evil consequence. And while we must blame 
surgery rather than physic for this invention, the consequence 
of a habit not unnatural, acquired from familiarity with the 
knife, or with mechanical methods of cure, it would be some- 
what difficult to explain upon what precise views a cure was ex- 
pected from such an operation; unless perhaps, where, by re- 
moving the whole of the painful portion, it might have been 
imagined that the very disease itself was cut out and carried 
away. 

But 1 formerly criticized perhaps even too strongly, what I 
trust is abandoned for ever; while also I need not say that the 
proposed remedy has failed, since the disease has very general- 
ly returned as before, after the separation of the nerve. That 
an additional evil, that, namely, of a partial palsy, should fol- 
low such an operation, was to be expected; adding aggravation 
to what it could not cure: yet perhaps it would be unjust to at- 
tribute such palsy, in all cases, to the operation, since I have al- 
ready shown that it is a frequent effect of the disease itself. It 
was to be expected, however, that the Neuralgia should some- 
times be removed, at least for a time, by such an operation; as, 
even that toothach which is not accompanied or excited by a ca- 
rious tooth, is often thus removed by extraction; the causes of 



CURE OP NEURALGIA. 423 

"which I have repeatedly explained. But it is also probable that, 
in these cases, the result would have been just the same had the 
operation been limited to a mere incision of the skin, and had 
the nerve been allowed to remain as before; while no one will 
now, I trust, again recommend even such an experiment as this, 
though we were not in possession of general and fundamental 
remedies, and further, even of local ones likely to be quite as 
effectual and much less grievous. As to those who have recom- 
mended such operations, I should be sorry to excite or renew 
their self-reproaches; but it would have been a false tenderness 
to have avoided the subject, while there remains, as I know there 
does, even a hankering after this painful and useless remedy; 
and, among some persons, a strong desire to prove that the prin- 
ciple, at least, was or is a correct one; a feeling which might 
easily lead to a renewal of the practice. 

With respect to the history of this practice, it seems to have 
originated with Andre, already named; or at least I cannot trace 
it beyond him: while it cannot be denied that he may be proud 
of the influence of his name in the numbers of his followers, if 
that can afford any consolation for the quantity of misery which 
he has produced. If his practice with the cautery has not equal- 
ly spread, it is probably not so much the fault of the surgeons 
as of the patients, at least in our own country, to whom this ex- 
pedient has, fortunately, always been one of insurmountable 
horror. In this the French surgeon and his followers appear to 
have had in view the eighty -fifth aphorism of Hippocrates, which, 
after enumerating the climax of remedies, in medicines, cutting, 
and burning, concludes by determining that if the last does not 
succeed there is no hope. Certainly, there has been no want of 
perseverance in the use of the knife, on the part of those with 
whom this is a favourite remedy for all and more than it can cure, 
and even in spite of almost perpetual failures; but that it may 
be understood, once for all, how far such perseverance can reach, 
I shall only refer to a case described by Lizars, which, for many 
reasons, I must decline quoting. 

Of general, not local, injurious practices or false remedies, if; 
is the simplest evil, while it is a negative one, that they not 
merely tend to exclude what is useful, but, by suffering the dis- 
ease to gain time upon us, serve to establish it and render it more 
difficult of cure. On that, however, I need not dwell; but shall 
content myself with examining what, while it is common, is di- 
rectly pernicious. 

It must already be obvious that what I have here to say re- 
specting all the Neuralgias or any Neuralgia, can be little else 
than a repetition of what I have urged on different occasions in 
treating of intermittents, particularly in their anomalous forms; 
while as relates to the neuralgic ophthalmia in particular. I have 



*^^^^^m 



424 CURE OP NEURALGIA. 

also been compelled to make similar remarks when speaking of 
the means of cure These observations relate to the evaeuant 
and debilitating system in all its modes, including low diet and 
abstinence from wine, purging;, chiefly by means of salts, and 
blood-letting, both genera? and local. 

It is not, however, in the marked Neuralgia (Tic) of the face, 
(that almost only acknowledged mode of this leading disease,) 
that these remedies are likely to be abused; as there is nothing 
here which can well lead even the most unobserving practitioner 
to confound it with inflammatory diseases, or with a flow of blood 
to the head;" while its own, separate, marking, name affords 
the usual empirical security against such abuses. And since, as 
far as this system is misapplied in neuralgic ophthalmia, I have 
already had occasion to point out the evils, I may here restrain 
myself to the few other cases where this abuse is likely to take 
place, or rather where it takes place every day. 

I ought, however, to remark previously, as concerning the 
whole, that the fashionable and frequent use of purgatives or 
systems of purgatives, and chiefly of salts and mineral waters, 
tends to aggravate all the Neuralgias, even to the Tic; causing 
them to recur or relapse, as it does the several forms of inter- 
mittent; and further, rendering them habitual, or incurable, by 
perpetuating that general debility and irritability of the nervous 
system, which is so fundamental a character in every disease 
whatever of this nature, local or general, that it must be inti- 
mately connected with the proximate cause; however impossible 
it yet is to explain the nature of that. And if such systems of 
purgatives are not absolutely prescribed by practitioners, direct- 
ly, as remedies of common and obvious Neuralgias, they are so 
prescribed for numerous affections and symptoms dependent on 
these diseases or on their cause, but not suspected of such con- 
nexions; while the almost universal fashion of self-empiricism 
adds a vast mass of the same pernicious practice, exclusive of 
the direct errors of physic itself. And thus, unwarily, are these 
disorders aggravated, perhaps, even to a certain degree pro- 
duced; while the practitioner who may chance to be consulted, 
is himself unaware of the cause, not merely because he may be 
ignorant of the nature of the diseases, but, even should he be 
fully informed of that, because he is not made acquainted with 
the nature or extent of the patient's own private practice against 
himself. 

I have already made so many remarks on the abuse of blood- 
letting in the intermittent, and especially in its anomalous vari- 
eties, as well as on the utterly mistaken views uuder which it is 
adopted for diseases of the head of the character under review, 
under the false hypothesis of fulness of blood and flow of blood 
to the head, while I have also been similarly obliged to point out 



CURE OP NEURALGIA. 425 

its pernicious activity in the production of paralytic disorders, 
that I could add little at present which would not be in some 
manner a repetition of what is past. Yet so important and so 
sweeping an error do I consider it, and so widely devastatory in 
its consequences, at present, being, as it is, a somewhat recent- 
ly revived practice, (revived, that is, as a fashion,) while it is one 
also that seems to be increasing in vigour rapidly, not only in 
England but in France, that I scarcely know how to pass it by in 
silence; though I at the same time feel that I am not justified in 
speaking of it further than as it concerns my own subject, far 
less in entering on it to the extent that would be necessary, 
had I treated of it on general views as it relates to physic at 
large. 

With respect to Parisian practice, including, as it dictates, the 
fashion, or gives the tone, to that of France in general, no one 
can be familiar with it without witnessing the pernicious effects 
of this system; while, renewed with a suddenness and an ar- 
dour, the causes of which it would not be very difficult to trace, 
did I here dare to enlarge so far, it is a revival, and in the same 
vigour, of that literally Sangrado system which was the subject 
of well known satire to professed satirists whom I need not 
name, and of remarks, even more instructive, from persons of a 
very different class; than which I could quote none more point- 
ed than those of Madame de Sevigne. May I give a single 
case in illustration, treated from the beginning to the end before 
my own eyes? and I may venture, because it is a case strictly 
belonging to my own subject. 

This unfortunate philosopher had been long subject to the 
usual dyspeptic and nervous symptoms of studious men, and 
was of a sallow and emaciated complexion; appearing, in fami- 
liar language, to be far more in want of additional blood than 
of its abstraction, while his disorder was continuously aggra- 
vated by a system of low diet, adopted on the same mistaken 
views. Passing every day with him, in company with an Eng- 
lish physician, it was easy to watch that over which he had no 
eontrol; as there would also have been no propriety in attempt- 
ing to oppose "the best advice in Paris." Headach was, as 
usual, one of the occasional symptoms; and on one unfortunate 
day he was induced to send for his surgical friend, by whom he 
was immediately bled. The headach, on the following day, 
continued, or rather returned, as it had formerly done, but with 
increased confusion of thought; the pulse and all else indicating, 
to the English physicians in question, increase of general debi- 
lity, and compelling us at length to offer advice, which was, 
however, opposed by the usual arguments. A second blood-let- 
ting of course took place; and the consequence was that he be- 
came, but only in the night, partially delirious; a result easily 
explained, in its very limitation. It was then determined in 

54 



426 CURE OV NEURALGIA. 






fall consultation, that there was inflammation of the brain, to 
the exceeding surprise, not without remonstrances, of the two 
English physicians; and, consequently, with the addition of 
blisters, shaving the head, and ice, another blood-letting was or- 
dered and practised. The delirium then increased, while the 
pulse became feeble enough, as might have been supposed, to 
have made any man reflect; but as this did not happen, or rather 
as the reflections took the opposite course, the practice was per- 
severed in, and on the following day the patient died: leaving 
the physicians, doubtless, convinced, as usual, that he had not 
lost blood enough. Such is a French case; but it would be easy 
to give no small number of parallels from English practice; and 
should it make no impression at present, the day will come 
round again when its value as w T ell as its nature will be under- 
stood. 

Did I dare to proceed, as to this practice in general and its 
present revived fashion, through all cases of its misapplication, 
I should far transcend my bounds, both as to space and subject; 
while it offers matter, in itself, for almost a treatise. It would 
be not less curious and interesting to trace the causes of its re- 
cent revival in such power, and of its rapid progress as a fash- 
ion; but from this also I must abstain. Yet a remark or two 
will not be irrelevant, even to the subject which is my own. 

If I must not examine all the causes, inflammation has become 
a fashionable term of fear, scarcely less than fulness of blood, 
and determination, " flow of blood to the head," while, to one 
or other of such imaginary causes, real enough however to co- 
ver a vast mass of imagination, it is sufficiently easy, with a pro- 
per quantity of inattention, ignorance, and confusion of thought, 
as of the indolence of some, and the hurry and want of time 
for thinking, of others, to refer to such causes more than half 
the diseases current in society. Thus the term inflammation 
having been but breathed or thought of, the imagination reverts 
instantly to bleeding, blistering, and purging; and the practice 
being as easy and obvious as the theory, there is no further oc- 
casion for study or reflection. The work of thinking is thus 
ready, the theory established before investigation; and as the 
lancet is always at hand, easy of application, and carrying with 
it the appearance of activity, the consequences are obvious. It 
is a universal saving of thought; and as a French provincial cri- 
tic of this very day remarks, forgetting, perhaps, that Le Sage 
had made nearly the same observation before he was born, it is 
sufficient that any young gentleman has been six months at Pa- 
ris, has acquired the term Gastro Enteritis, and the use of the 
lancet and the leeches, "-to return into the provinces an accom- 
plished physician, the aid-de-camp of sextons and undertakers." 
And thus it is also that, in Scotland, from the popular use of the 
term Brain-fever, and the natural confusion of thought thus pro- 



CURE OF NEURALGIA. 427 

duced as to inflammation of the brain, a similar practice is, in 
the country at least, almost universal, in the worst cases of re- 
mittent, or even of typhus, with symptoms of debility, not of 
inflammation: the delirium maintaining the error. Such is the 
dangerous nature of terms. 

If any secular reader (presuming this essay may have such 
readers) should hesitate in believing that a science like physic 
and men like physicians should be governed by fashions, should 
he treat the satire of Moliere and Le Sage and Sevigne as pure 
and groundless satire, he will find proofs of another kind in the 
history of the sect called Hemophilites in Italy about the year 
1795; the period of a contest not less acrimonious than that of 
the Guelphs and Chibellines, excited by means of two words, 
the invention of a man, a Scot, whose disreputable influence 
over the science by means so worthless, will not soon be forgot- 
ten. It was then computed that in various towns of Lombardy, 
in which the population reached from fifty to sixty thousand, 
the average people lost, each, from two to three pounds of blood 
per annum; this calculation having been verified by careful ap- 
proximations: while for those, of course, who were so fortunate 
as to escape the physicians altogether, the others must neces- 
sarily have compensated by a heavier tax on their own arteries. 

And if I have quoted some authorities against the practice of 
blood-letting in the disorders of this class, when treating of fe- 
vers, in the first volume, I may here add one of no small weight 
then omitted, namely, that of Amati of Naples, who, very un- 
ceremoniously, pronounces it to be Death. That it is the very 
frequent cause of death, even in our own country, while the 
disease obtains the blame which should fall on the physician, 
every year's additional observation convinces me; and not one 
more than the summer (1827) which has intervened between 
the printing of the first and second volumes of this work; a sea- 
son perhaps even more noted than any of the immediately pre- 
ceding mortal ones, for the ravages of Marsh fever under all 
its forms. Yet it is a season which, aided by the propagation 
of the present opinions on Malaria, through that essay which 
was the precursor of these volumes, has, I am pleased to see, 
made a formidable inroad on the vulgar opinions as to the com- 
mon existence of Typhus, as it has justified those remarks on 
the whole of this subject which commenced in being ill enough 
received: at length seriously turning the attention of English 
practitioners to the entire subject of Marsh fever, and with the 
prospect of consequences that cannot fail to be beneficial to a 
wide extent. 

But if, to say how fashions originate, and are established and 
propagated, would require rather the pen of the moralist than 
the physician; there is one cause which, trifling as its powers 
might be esteemed on a superficial view, is far more active than 



428 CURE OP NEURALGIA. 

superficial thinkers would imagine; while it is in truth the histo- 
ry of every fashion, springing often as they do, out of the most 
contemptible accidents, or from the most contemptible, and of- 
ten absurd individuals, and propagated by that great sweeping 
principle of imitation or habit by which mankind is governed, 
sometimes even against common sense, as cattle obey some noisy 
gibberish of their driver. In this case, some professor in a fa- 
shionable school of phj^sic, from personal opinions perhaps re- 
specting his own constitution, or from the necessity of saying 
something different from his predecessor in the same chair (a 
necessity well understood) or from any other cause, commences 
by persuading himself, first, that wine is pernicious, or absti- 
nence useful, or that he himself or some one else contains too 
much blood; while, accustomed to repeat this annually, he gra- 
dually increases in violence, learns to see all diseases through 
a false medium, and becomes the founder of a fashion; a fashion 
propagated and multiplied in a sort of geometrical ratio by the 
herd of his hearers, who, naturally and innocently enough, trust- 
ing to high authority, cease to think for themselves, or rather, 
never acquire that art; remaining, to the last, the sectaries of a 
system founded by their " magnus Apollo." But I have said 
as much as I dare to borrow space for, and as much indeed as 
is necessary, since far more would be equally useless: while I 
should think it on the contrary, far too little, if, by writing, I 
could induce the sectaries of this fashion, as far as it is a fashion, 
to review their practice, and to restrain their hands and their 
lancets to the cases, numerous enough, in w T hich this is the real 
remedy; cases where, perhaps, from habit, often from that of 
trifling with it, they too often fail as far short of the necessary 
activity and vigour in the use of this great and valuable reme- 
dy, as they misapply it in others. 

But whatever may be the evils as to the diseases which be- 
long to Neuralgia, that arise from general blood-letting, I sus- 
pect that they are much exceeded, arithmetically, or as to pa- 
tients or cases, by those which flow from cupping; a practice, 
also, which we must view as one of the fashions of the day, 
originating in the various false theories already pointed out 
And as I took no notice, or an insufficient one, of this practice 
in my former remarks on the maltreatment of these disorders, 
it will be necessary to do so before I bid adieu to this subject. 

It cannot be unknown to any one, that while the practice of 
cupping was formerly a branch of the barber's occupation, it 
has lately, almost recently, gained in dignity as in extent; the 
number of those who profess it as a distinct trade having much 
increased, though at the same time the persons who conduct this 
art have not gained in point of intellect and attainments on their 
more multifarious predecessors; while, consonant to the laws of 
political economy, the price of their commodity has been mate- 



CORE OF NEURALGIA. 420 

rially enhanced, rendering them in fact the rivals of physicians 
themselves. 

As a law in that science, a trade may be thought not to be es- 
tablished, or a commodity manufactured, till after the demand 
has arisen; while, in proportion to the demand, is the commo- 
dity, as are also its venders, multiplied. But if this be true, 
there is also such a thing as a forced market, or an artificial one; 
when the mere exposure of a fanciful commodity, or the know- 
ledge that such a one exists, creates purchasers; leading to fan- 
ciful or artificial wants, before dormant or unfelt. This is pre- 
cisely what has happened respecting cupping: it is talked of, 
and therefore it is wanted; there is a cupper in every street, 
and it becomes necessary to employ him. 

Nor is this a caricature of the truth, even as it relates to prac- 
titioners in physic; to whom it has become a more ready and 
acceptable expedient than when the office fell on themselves, 
generally little able to perform it or to give up the requisite 
time to the operation; while, with regard to patients, self em- 
pirics or otherwise, it is a fact known to all, and to which, 
many will, I believe, plead guilty, or at least conscious. But 
it is necessary to inquire more particularly into the economical 
details of this practice, as well as its medical application and 
consequences. 

In those nervous affections which I formerly described, and 
in the more decided neuralgic headachs, there are many cases 
which, though still viewed under the false system of " fulness" 
and " flow of blood to the head," are not thought to justify ge- 
neral blood-letting, as there are many more where this expe- 
dient is not hazarded above once, or perhaps twice; possibly 
however oftener. Here, cupping becomes the substitute; since, 
of leeches, less in fashion in England, though peculiarly so in 
France, I need say nothing, inasmuch as the same reasoning ap- 
plies to both, with some slight modification. In whichever 
mode this expedient has gained a footing, it continues to be re- 
sorted to on every return of the same symptoms; being simi- 
larly and equally abused in palsies, whenever the imagination of 
the patient or the practitioner can find a reason for it, and with 
the same ruinous consequences. Thus, in the neuralgic disor- 
ders, as in all the nervous affections from whatever cause, that 
aggravation in all its modes is at length produced, which I have 
so frequently pointed out as following the evacuating system: 
and the final destruction of the patient's health, often of the pa- 
tient himself, becomes a consequence from which it will require 
good fortune to escape; good fortune added also, often to youth 
and resistance. 

But whatever blame may fall on physic for the invention, or 
rather the misapplication of this practice, though all the con- 
templated evils might have been produced by practitioners, 



430 CURE OF NEURALGIA. 

they are not so in reality; since, in perhaps a large proportion 
of cases, the patient becomes his own physician. Economy, 
weariness, any other cause, operating with a prolonged and chro- 
nic case, induces the patient to pursue, from his own motion, 
that which has once been pointed out to him as the remedy for 
his disease; and thus the cupper, whose whole circle of know- 
ledge is comprised within the circle of his glass, and whose in- 
terest it is to operate as often as possible, becomes the joint phy- 
sician in the case. And thus do others, even without medical 
advice, labouring under sensations which themselves pronounce 
to be a " flow of blood to the heed," and knowing that their 
neighbours have received such advice in siuiilar cases, commence 
and pursue the same system c practice; while the operator, 
even were it not his interest, cor emplating this one subject, and 
no other, through a whole life, 1 iomes also the adviser or abet- 
tor: and, possibly, cobscieiitidus > enough, as far as his capaci- 
ty for acquiring what is comm.; ly called conscience extends, 
convinces himself that the blor^ 1 of all mankind flows to the 
head, and that there is no salvation for human nature out of the 
precincts of the cupping-glass. 

An unfortunate belie" has much added to the extent of this 
persevering system of blind suicide; and that is, an opinion 
that it is a very innoceni. practice, that " it can do no harm if it 
does no good/' and suth other philosophy as is current with 
the vulgar intruders int physic. Hence it becomes almost an 
amusement; persons talis of going to be cupped as they might 
of dressing or shaving, or there is established a day for cupping., 
as, in the former times of physic, blood-letting was to be per- 
formed under the directions of the moon and the almanac. And 
how frequent this practice is, how frequent rather it has become, 
we may convince ourselves, even as spectators in general socie- 
ty, by the sight of marks as conspicuous as they are frequent 
in females, and especially in youthful ones; since we may look 
in vain for the same records of abuse in the grandmothers of 
all this youth and beauty. So much has the blood altered the 
directions of its flow, even since the days of our immediate an- 
cestors. 

But to pass from what, if it be satire, is rigid truth, while it 
is a satire of which I shall not repent if any good shall arise 
from it, let us see what are the actual consequences of this prac- 
tice, particularly when persisted in, or become habitual. 

Physicians need not be told, that whether blood is abstracted 
in this mode, or by the lancet, periodically, or frequently, there 
is a tendency produced to replace or restore it, and that what 
was once under command, frequently becomes a dangerous ne- 
cessity. Yet in cases where this practice is misapplied, that re- 
storation does not remedy the evil effects, which go on progres- 
sively, though probably much more slowly than they would have 



CURE OP NEURALGIA. 431 

none, were it not for this expedient which Nature has provided 
as a remedy for losses of blood. There is a gradual accumula- 
tion of the debility, the irritability, or the nervous diseases, be 
those what they may: while, in this progress, fresh symptoms 
appear, or the former ones are aggravated, so as to induce, still 
further, a temptation to the repetition of the remedy at first 
adopted under false views. And where the diseases in question 
are decided cases of the Neuralgia, under any form, all those ef- 
fects take place which I have so often described; while each new 
application of the remedy, resorted to for fresh relief or fresh 
symptoms, tends to co ifirm and aggravate the disease, and, very 
generally, to induce f new ones; even to those heavier conse- 
quences, epilepsy, palsy, fatuit , and mania, which I have al- 
ready pointed out. t \ 

As on other occasions. I ma> ^ere taotice a case or two of this 
nature, with the hope of pro, .>singp a stronger impression, at 
least on ordinary readers, than^y general statements can be ex- 
pected to do. 

A middle-aged man, previously vigorous and healthy, to whom 
I had the access of a friend, was seized suddenly, and from ex- 
posure to Malaria, with the Neuralgia ^a a most regular perio- 
dical form, attended by much derangement of his general health, 
including what is called dyspepsia. Being opulent, he of course 
consulted the physicians and surgeons most in vogue; going the 
round of a tolerably wide circle. As tl ( 3 pain was not in the 
cheek, but on the back of the head, it was not perceived, or not 
admitted, to be Neuralgia; and as no one sought for the intermit- 
tent fever, it was agreed that this was a " break up of the con- 
stitution:" and dyspepsia, and nerves, and bile, served to ex- 
plain what was not a " flow of blood to the head," and a threat- 
ening of apoplexy, and of palsy, and what not. 

Blood-letting was of course adopted, but without producing 
a cure: on the contrary, the patient became worse, and then 
cupping was resorted to, while at every cupping he became gra- 
dually worse: till at last the pain ceased suddenly, and the fa- 
culties became impaired, and there at length supervened epilep- 
tic fits. These results required about six months of vigorous 
practice to produce, the patient being himself vigorous. Of 
course, the epileptic fits proved that there was congestion in the 
brain, or an abscess, or a tumour, or an ossification, or some- 
thing else, and that the original (neuralgic) pain had been an in- 
flammation in the pia mater, or in the dura mater, or elsewhere. 
Therefore the cupping was to be persevered in, and it was per- 
severed in; and, at length, the epileptic fits began to occur many 
times in a day, and it was pronounced that death must follow. 
But the patient was not very easily caused to die: an accident 
compelled him to leave home, physicians, cuppers, and all; lie 
found something else to do, became a little better, began to for- 



432 CURE OP NEURALGIA, 

get the necessity of cupping, recovered in spite of the abscess 
of the brain, and enjoyed his former health for many years. 

Patients, however, are not always so fortunate in these cases. 
Almost at the same time, in the same place, his friend, a mutual 
friend, was attacked in the same manner, and put under the same 
treatment, in the same hands. This person had the disadvan- 
tage of being twenty years older, followed the same course, in 
the disease as in the remedies, became fatuous, and died: — whe- 
ther of the cupping or not, the reader must judge for himself. 

These are but specimens: I could fill pages with parallel ones, 
under endless variations, but I need not; knowing well that they 
who have treated such cases and reasoned on them in the man- 
ner that. I have condemned, will not yet learn to distinguish be- 
tween the diseases which nature gives us and those which they 
produce themselves. It is fully as easy indeed to retort on my 
explanation, that it is wrong, as it was to proceed on the opposite 
views originally: as it must ever be where opinion, commonly 
called conviction, is made the test of right and the substitute for 
argument and proof. It is my own hope that I have produced 
both proof and argument, in all that has preceded; nor without 
such, should I, or indeed could I, have formed the opinions in 
question; since there was nothing to generate them but evidence, 
and since it was the difficult office of that evidence to change all 
the previous conviction, or opinions, that had been instilled into 
myself, in common with others, by authority, reading, and ex- 
ample. 

Let me yet be permitted to make one general remark of the 
same critical nature, on a situation of things as to the popular 
health, which cannot fail to be known to the people at large as well 
as to physicians, if it has not led, in their minds, to the same con- 
clusions. I cannot say that I have exactly witnessed the rise of 
it; but I have no hesitation whatever in saying that I have seen 
its rapid increase, and that wherever I do trace it, it is in situa- 
tions where fashion, habit, or what not, have rendered physic 
more of a necessary of life, or a luxury, than it is in other 
places; or in families, as families there are, which, from various 
causes, rely much on physic and physicians, or, from whatever 
reason, act as if life could not go on in its ordinary course with- 
out the aid of medicines. 

The general fact in question is, that in such cases, we -often 
find young persons, and chiefly, as might be anticipated, young 
females, always also, of course, in the opulent or easy classes of 
society, labouring under chronic disease, frequently during a 
long period of years, and to such an extent as to be disabled 
from all exertion; often, confined to their bed-chambers, and, as 
might be expected, with minds as much subverted as their bo- 
dies are deranged. And while such persons are under the al- 
most daily discipline of physic in some shape, we see nothing 






CP&E OF &'E If II A LGI A. 433 

in their appearance, and find nothing in their descent or consti- 
tution, to justify such a state of things; while, further, no name 
can be given to a disorder, of which indeed we can scarcely de- 
fine any one symptom in a satisfactory manner; unless the term 
nervous, or flow of Wood to the head, or dyspepsia, or liver 
complaint, or some such convenient and fashionable phraseolo- 
gy should be resorted to in explanation. 

Now, if we except consumption (and really there is little else 
to be excepted, while I need not say to physicians what those 
disorders may be,) the nosology possesses no chronic disease 
which can thus occupy the youthful years of such unfortunate 
persons: since we can scarcely avoid smiling to hear of liver 
complaint, lasting for years, in a young person, in our climate; 
continuing in a young lad} r , perhaps with the complexion of ala- 
baster, often even with a frequent if not a constant mixture of 
the ruddiness of health, from seventeen to thirty or more, and 
where not the slightest real evidence of a diseased liver can be 
produced. There are no diseases in the catalogue for such youth, 
such habits, and such constitutions, to justify such a state of 
things; but, nevertheless, there are not wanting causes enough 
for all that is obvious; for nervous affections, deranged digestion, 
with their trains of headachs, debility, mental feebleness, and 
much more. 

And these causes will be found in the abuse of physic. We 
can trace it all to purgatives, to cupping, to blood-letting, to one 
or all of these; aided by confinement, restrictions, diet, and 
aided also by the aberrations of mind partly consequent on such 
treatment, and partly the result of moral causes often sufficient- 
ly obvious. This is the disease of physic, though not always 
the produce of Physicians ; abundant enough at all places and 
times, in the same situations, and from the same causes, if in 
minor degrees; the frequent jest of the satirists of all days, 
when slight, as it is the torment at once and the harvest of phy- 
sic. And, as such, it may often, in reality, be matter of con- 
tempt; as it also is a business or an amusement, or the basis of 
a luxury, to those who have no other occupation. But, pursued 
to this excess, rendering the days of youth useless, destroying 
the mind with the body, and nursing up a morbid imagination 
with a disordered body to endure that length of life which it 
does not easily succeed in shortening, it is a fashion at which 
we can no longer smile, but which would, on the contrary, de- 
serve the severest reprobation, if we could hope, by censure 
and exposure, to produce that reform which will take place ul- 
timately, only in the same manner as the evil arose; from change 
of fashion. 

And it would scarcely exceed the truth to say, that in any 
chronic complaint, in any person, and especially in any female 
under thirty, or even far beyond, if we except some rare ca 



434 CURE OF NEURALGIA. 

Hydrocephalus, it is impossible that cupping, or bloodletting, can 
ever be necessary, under the presumption of disease of the head, 
and very rare that this can be required for any acute one; that 
where it is practised it is generally injurious, and, if frequently 
adopted, highly so; while when we perceive the visible testi- 
monies of this practice in such persons, we may almost decide 
on two things; first, that the practitioner has been ignorant, as 
well as culpably violent, and, secondly, that he himself is the 
sole cause of the ill health. To judge where he has been the 
cause of death itself under such proceedings, is not more diffi- 
cult. 

It were well indeed if not only ruined constitutions, but even 
death itself, were not the frequent, the almost daily result of 
physic thus misapplied in all the analogous and parallel cases, as 
also in some others: the produce of a combination of system, 
fashion, and ignorance, which renders Physicians and ph} T sic 
the just terror at present of all those who can see and distin- 
guish. It is difficult to speak without high indignation as well 
as horror, of what we thus daily witness: to suppress the for- 
mer is impossible, when our own, perhaps dearest friends, have 
thus been destined: and well now, perhaps, will he decide, 
who, like Napoleon, resolves to exclude this art and its profes- 
sors entirely; for, on the arithmetical average, he will assured- 
ly be far on the side of security. It is but to open our eyes to 
see the truth of this every day; while if it is over the ruined 
health, or the life, of females that we shall most often have oc- 
casion to grieve, from the obvious reason that in them the ner- 
vous affections thus mistaken and maltreated, chiefly abound, or 
are chiefly brought before physicians, so has there been a rapid 
increase of the evil, from the numbers who, returning from a 
continental residence with the consequences of marsh fever 
which I have so often described, have been subjected to this., 
truly mortal as well as mistaken treatment. Nor do I overstate 
the facts, when, out of innumerable cases of a parallel or analo- 
gous nature which I might quote, I have seen dropsy produced 
by perseverance in violent blood-letting, in a healthy female of 
seventeen, of a peculiarly sound constitution: her sole disorder, 
as the event proved, being an intermittent headach, of little mo- 
ment, following a common remittent fever; and this gross and 
almost mortal, not error, but systematic wrong, the produce of 
a late, unhappily celebrated, professor formerly alluded to, for 
whose aberrations of mind on this point, and for whose violence, 
there are thousands on thousands alive to lament, besides the 
thousands long past regret or suffering; since, in such a case as 
this, it is not to the mere personal wrong that the evil is con- 
fined. Such a system, promulgated by the authority of a Chair, 
necessarily propagates itself almost in a geometrical ratio; in- 
fluencing to similar and widely spreading wrong, the thousands 



CUKE OP NEURALGIA. $25 

"who have no other guide but authority; imitators, mimics, the 
slaves of opinions, and schools, and fashions, and teachers. If 
deeply have such Teachers especially to answer, deeply also has 
physic in general to repent of all this destruction: how those 
may feel who, hereafter perhaps discovering that the} r were 
wrong, may also bethink themselves that want of knowledge, 
proceeding from want of exertion and study, is no excuse for 
misconduct, still less that arrogance, or the pride of place or 
system, can never become him to whose charge are committed 
human life and happiness, it will be for them to answer when 
the time of reviewing the good and evil which they have done 
in the world shall arrive. 

I must not, however, terminate these remarks, without making 
one observation on the subject of cupping, which applies equally 
to blood-letting, and which I reserved to this place. It is a re- 
mark of importance, as it tends to controvert, I hope to demo- 
lish, one argument in favour of this practice, and which, appear- 
ing to be founded on experience, is the most mischievous one 
with which the present views have to contend. 

It is said, and indeed it is matter of daily experience, that in. 
all such cases, immediate relief is procured by blood-letting in 
either of these forms; and as the same relief is similarly pro- 
duced in cases of decided inflammation, as in others in which it 
is an acknowledged remedy, the analogy seems sufficiently per- 
fect to form a justifiable argument. Unfortunately, still more 
unfortunately, patients themselves become so convinced; so con- 
scious in fact of this relief, that they are always ready to de- 
mand it, and, still more, to resort to it without advice, or against 
that, on their own notions and opinions. 

Physicians surely know full well that there are numerous 
cases of daily occurrence, in many diseases, even in inflamma- 
tion, where though such immediate relief is procured, they re- 
fuse to adopt the remedy, from experience of its ultimate evil 
consequences. Such is the result in all the cases under review; 
for, be the immediate relief what it may, the disease is ultimate- 
ly aggravated; whether or not we can clearly explain the source 
of that temporary abatement of disease, or rather, what is the 
real fact, the temporary abatement of suffering. If, in inflam- 
mation of the lungs, after a certain stage, there is scarcely an 
instance where such relief would not be obtained, while at the 
same time the physician knows full well the danger of seeking 
it in this manner, that also is, generally, true of fevers; pro- 
ducing the same caution in the hands of judicious practitioners, 
but, among others, leading to the abuse of blood-letting; to 
that abuse which has recently spread in so remarkable a manner. 

At another extreme, if we take a case of decided nervous dis- 
ease attended with the greatest possible feebleness, irritability, 
cmaciation, with every thing, in fact, which proves, or at le.isr 



43l> CURE OP JSEUKAL&IA, 

did prove some years ago, to the satisfaction of ail physic, a 
case requiring the exactly opposite mode of treatment, and if, 
in such a case, there is any local painful symptom, or any pecu- 
liar local inconvenience, the effect of blood-letting is a sudden 
relief to that symptom; and sometimes also, one, as sudden, but 
equalty temporary, to the whole train of inconveniences. Here 
then is a temptation, but it is one which every judicious physi- 
cian resists, or which at least was resisted, not very many years 
since, without, hesitation; it being then well known that the ra- 
dical disorder was thus increased. 

The effect is precisely the same in even the purest Neuralgia; 
in the Tic; or the pain is removed at once by a sufficient blood- 
letting; while I hope that every one will now be agreed in be- 
lieving, that this pain is rot the result of inflammation, or even 
of an inflammatory tendency, in the system, and while, in reali- 
ty, that remedy is scarcely ever adopted at present, notwith- 
standing the opinions of a few, and of no small reputation for- 
merly alluded to, who conceive such diseases, in certain cases 
at least, to be inflammations of the nerx'es. I do not pretend 
accurately to explain the cause of this relief; but can conceive 
it to arise from that diminished sensibility which is immediately 
produced by loss of blood; an effect which, when in excess, 
constitutes fainting: from a very obvious cause, the diminution 
of nervous energy. 

Hence, if I am right, it is easy to see how, in every case of 
nervous disease and debility, with local symptoms, or with suf- . 
fering of any kind, the same effects will follow, as they also do 
so often in fevers, and in exhausted inflammations; while it is 
further easy to understand how such relief will be most sudden 
and complete in those whose nervous system is in the greatest 
state of debility j exhaustion, irritability, or by whatever term 
we choose to suggest what we as yet know not how to define, 
And, in proportion to this previous debility of the nervous sys- 
tem,- is the relief produced by inducing additional debility in 
this, sudden and effective; whence the very singular and well- 
known effects produced by even the most minute loss of blood 
in such cases. And this increases the temptation, to the injudi- 
cious, to those who do not reason; not on]y in the nervous and 
neuralgic cases, under review, but even, as I before insinuated, 
in fevers and exhausted inflammations; confirming them in a 
practice founded, as they believe, on that, most abused of terms, 
experience, but, in reality, on that mistaken experience which 
is truly the " experientia faliax" of physic, as it is the equally fal- 
lacious experience by which the mass of mankind, through all 
their relations, are misled. I might illustrate this view still 
further, by the effects of excessive blood-letting in hydrophobia, 
I think also in tetanus, and, assuredly in hysteria, where it has 
often been grossly abused: but I feel that it would lead me into 



CURB OE NEUftALftlA. 437 

a discussion which I have no right here to enter on; into one of 
those inquiries which have so often been forced on me from the 
necessity of illustrating the proper subject in band, and which I 
have striven to quit at the moment they have begun to lead me 
from the main object, whatever important views they might 
open as to other departments of the practice of physic; as the 
present one assuredly does. 

To proceed, while such relief is caused hy a temporary and 
sudden diminution of the nervous energy, producing temporary 
insensibility as an immediate consequence, it is plain, that, if a 
diminished nervous energy, or a peculiar state of debility and 
irritability (since I must use these received terms for want of 
better) is either the cause of these diseases or at least an essen- 
tial condition to their existence, the general, perhaps slow, re- 
sult, must be to augment that morbid condition, and thus to ag- 
gravate the disorder. And this general reasoning agrees pre- 
cisely with the evidences that have been brought forward through- 
out the whole of this essay; in w*hieh if. has been proved that the 
neuralgic diseases are dependent on, or connected with, such a 
-state of the nervous system, and that all debilitating proceedings 
tend to aggravate them, and to render them more difficult of 
cure, or incurable. Thus do general reasonings, derived in 
different ways and through different analogies, coincide, with 
the observation on the real remedies and their effects, and also 
with the deductions drawn from the evil effects of erroneous re- 
medies, to establish and to confirm, in a variety of modes, the 
truth of the views which I have held out through the whole of 
this essay, and respecting all the diseases united under its com- 
prehensive plan. 

On the subject of the cure of this disease, I have long hesi- 
tated whether I should add a remark, respecting the general 
truth of which I have not fully satisfied myself, and which I 
have at length with difficulty resolved to add before it is too 
late, and while this page is approaching to the press. Yet if 
eventually found to prove less just than I imagine it to be, it 
can, with this provision, lead to no erroneous conclusion, as it 
is incapable of doing harm. It is this: that while Neuralgia is, 
always I believe, very generally it is certain, accompanied by 
an intermittent febrile condition, it is possible to cure the for- 
mer, and very often, while the latter continues uncured. I 
think that I am certain of the fact, as to a great number of 
cases; of a certain proportion, I can have no doubt: but while I 
have, throughout this essay, been cautious of advancing any 
thing as truth, unless the evidence was uncontrovertible, from 
being sufficient and pure, I will not run the hazard of bringing 
discredit on the whole, by ranking with it what is less decided- 
ly or generally proved. Others must inquire for them selves ; 
while I think that various circumstances which 1 need not now 



438 CURE OF NEURALGIA. 






recall to the reader, in the history of this disorder, render it 
probable that this can be the case, and that what is a symptom, 
and not the entire disease, can be detached, or cured, while the 
radical disorder remains; an occurrence, I need not say, to which 
physic, in many cases, presents sufficient analogies. 

And the remark is an important one: because, however the 
Neuralgia itself may be removed, the disorder cannot be consi- 
dered cured while the febrile disposition remains; or it is neces- 
sary to extirpate the chronic intermittent also, lest, at any fu- 
ture time, under its influence, or protection, the painful disease 
should recur in this part, or possibly in some other one. And 
this fact being ultimately proved true, or rather, a frequent 
truth, as I think it will be, we see an additional value derived 
from that theory which considers Neuralgia as a symptom or a 
mode of intermittent; though even without this, there is no 
want of valuable practical results to be derived from that theo- 
ry. It is also evident that if, under this case, I refer to the en- 
tire cure of the whole disease or disposition to intermittent, for 
ever, so "this reasoning applies to the cases of single attacks or 
relapses; since the fact, as I view it, is also this; that in what 
may be a six weeks' relapse, for example, of the intermittent 
with the Neuralgia, this latter portion, the pain, may be removed 
within a few days, while the febrile state will run its full time 
if the medicines should then be abandoned. Such a eure there- 
fore would be less perfect than we might, possibly, render it: so 
that the Neuralgia might return again even within this assumed 
period, or recur at a future time with the return of the chronic 
intermittent. 

I have no more to add respecting the cure of Neuralgia; w T hile 
I regret that the necessity of dividing my subject in conformity 
to established opinions, and of combining a train of evidences 
and arguments, respecting almost every disorder here treated, 
with the description of these disorders and the modes of treat- 
ment, both correct and erroneous, should have led to a dismem- 
berment and a repetition, which, should 1 ever be able to renew 
this essay, with the support of the medical profession instead of 
its expected dissent, I shall be, myself, the first to rectify, and 
to replace by a far different order and arrangement; an order 
which, if already arranged in my own mind, I must at present 
contemplate in hopeless silence. 



439 



CHAPTER XXXI. 



Conjectures respecting the Condition of the Nerves and Ner* 
vous System in the Intermittent and Neuralgic Diseases. 

I consider the essay which I undertook, to be now finished; 
as every essay of such a nature, resting on evidence, induction, 
and experience, ought to be completed when evidence is ex- 
hausted and induction carried as far as it can safely go; and when, 
from both, confirmed by experience, a method of cure, as far 
as one has been ascertained, has been laid down. Yet, if there 
could be discovered or proved a proximate cause, an investiga- 
tion of that subject would not only be essential to such an essay ? 
"but would be productive of decided advantages, by uniting, 
under one leading principle, phenomena, diseases, which not- 
withstanding the several analogies by which they have been con- 
nected, still present too many 'differences, while they want thai: 
great link which is indispensable in every philosophical view of 
phenomena. 

This, however, I have already disclaimed; since, unable to 
form ideas on this subject, I will not follow the too common 
practice in physic, of deceiving the reader with empty words. 
Our ignorance of the nervous system, in its whole, in its de- 
tails, in every thing but its visible distribution, is radical and 
complete: it is entire, absolute ignorance, in spite even of re- 
cent attempts to elucidate it, and of a few scattered facts of 
small value; and till all shall be done, in a pursuit where there 
is scarcely even a commencement, it will probably be vain to 
attempt the explanations desired; while, of that, we can at pre- 
sent see no prospect, scarcely even conjecture by what road we 
are to make the attempt. 

Still, I may venture to make a few remarks on circumstances 
connected with these diseases and with the condition of the 
nerves in them, for which no convenient opportunity has offered 
before; and I am indeed bound to this by the promise made in 
the chapter on anomalous intermittents: while, had such op- 
portunity happened sooner, these observations would scarcely 
have been intelligible till all the facts with which they must be 
connected had been detailed. It is a task nevertheless ihat I 
would have avoided, had I dared; sensible that it must be un- 
satisfactory, and that even had I any peculiar ingenuity to exert 



440 STATE OF THE NERVES IN 

upon it, the best result may prove, perhaps, some approbation 
from the youthful practitioner who sees all physic as we perhaps 
all saw it in the days of our debating societies, and the silent 
doubts of the rational and philosophical physician. 

Though what I have to remark is but brief, and as far as ap- 
pears to myself, of very little real importance, I cannot even 
say that little, without observing on one difficulty, singularly 
irrelevant, in reality, but not the less vexatious, which in li- 
mine, tends to obstruct or encumber all inquiries into the pa- 
thelogy of the nerves or of nervous diseases. It is founded 
on the abuse of a term long popular, and on a perverted view, 
in the public mind, of the meaning of the terms nervous, and 
nerves, as applied to disease or to health. Nor is physic itself 
here innocent; since, while it may in a great measure be accused 
of being the founder of this perverted acceptation, the opinions 
of the value and meaning of these words are little different in 
the minds of the mass of practitioners from what they are in 
those of the public at large. 

It is almost superfluous to say what the popular, or, in reali- 
ty, the only existing meaning of these terms is, in. the minds 
of both parties; while it may be considered a singular instance 
of the power of terms, and of the habit of thinking vaguely, or 
of not thinking at all, of using words without meaning, or un- 
der false meanings, that even anatomists, physiologists, physi- 
cians, often seem to forget what they know or knew; forget 
what the nerves are, and what offices they really perform in the 
body, and follow the herd of the ignorant and thoughtless, not 
only in this lax manner of speaking, but of thinking, if think- 
ing it can be called. If, by the multitude, too generally by 
both multitudes, the nerves are spoken of, even in more serious 
views of disease, as a kind of metaphysical entities, or rather 
non-entities, it is as if they w r ere air, spirit, an idea without 
prototype, nothing; while ine word nervous, as applied to dis- 
ease, is equally understood to mean something unappreciable by 
human investigation; the misfortune of a feeble body or a fee- 
ble mind; a term to be applied only tb weak women or more 
cowardly men, a property of the valetudinary or the hypo- 
chondriacal, a " permission of the will,'' an imagination. To 
possess weak nerves, or bad nerves, or, reversely, to be without 
nerves at all, such language and more is not purely phraseology, 
but is, in reality, an abstract of the popular philosophy on this 
subject; and the philosophy of physic in general is, here, far 
too much iike that of the people. They may not indeed know 
it, but anatomy cannot easily forget that the nervous system 
forms a bulk}', weighty, portion of the body, capable of being 
dissected and traced, equalling in extent, in intricacy, in distri- 
bution, the more favoured circulating system, though not j'ield- 
ing blood to a sabre-cut or a lancet, ar id therefore somewhat le** 






MARSH PEVER AND NEURALGIA. 441 

vulgarly obvious. Nor can physiology and physic well forget 
their offices: forget that it is not the circulating system, that 
system which has almost drawn all favour and attention to itself, 
even in their minds, (as, to the vulgar, it bleeds, and bleeds the 
man to death,) but the nervous system, which is the prime 
mover; the cause even of all circulation, of all motion, of life 
itself; that it is The Life: that the Nerves are The Man, the 
Animal: and that every thing else, the whole animal structure, 
in all its parts, is a mere machine, and a chemical laboratory, 
as purely subservient to the nervous system, as is a steam-en- 
gine to the intelligence of man. Without a nervous system, 
there is no animal; there can be none: without a circulating 
one, there are myriads. 

The " nerves" are in truth, the very animal itself; and yet 
while the vulgar, pardonably enough, forget this or know it not, 
physic abets, and has abetted them from its earliest infancy: 
searching all the remainder of the body, every subordinate, for 
diseases and their causes, yet scarcely casting a retrospect to 
that which is the basis and fountain of all disease, as of all health; 
except perhaps, occasionally, as under the banner of Hoffmann, 
to produce some fanciful and sectarian theory of spasm, and, 
even then, recurring to its favourite circulating system, while 
forgetting the prime mover: just as if he who would correct the 
faults, or study the motions of a clock, should agree with him- 
self to omit the pendulum or the weight. 

If the nerves must thus be the prime seat of all disease, and 
the animal structure, its mechanism apart, is a chemical labora- 
tory, yet, trifling as chemistry trifled in its early days, this was 
forgotten* and has hardly yet been understood, except by the 
few, I scarcely know whom to name, who are chemists in a very 
different sense from the popular and received one; chemists in 
even somewhat more than iodine and potash and equivalents. 
And when I say this, I do not forget that there has been what 
was called a humoral pathology; since I surely will not insult 
chemistry by ranking such empty speculation as this produced, 
under so respected a term: and as little think it needful to exa- 
mine that system which sought for the causes of disease, or for 
disease, in the philosophy of mechanics, in the solution of in- 
solvable hydraulic problems, or in a system of dynamics attempt- 
ing to operate without the very elements of calculation, and not 
only thus, but forgetting the very moving force, the nervous 
system, neglected by the humoral and mechanical philosophy 
alike. And it is the immediate, the prime, the chief office of 
this system to maintain in action, the chemistry of this struc- 
ture; since, without that chemistry, the mechanism of the ani- 
mal falls to pieces and disappears; ceasing to act long before 
that ultimate event. Where then should disease be sought? che- 
mical laws are invariable: chemical actions must proceed by 

58 



442 STATE OP THE NERVES- T8 

those rules which have been imposed on matter, and through 
the agents, yet unappreciable, which govern them. These ac- 
tions, subordinate, consequential as they are, cannot cease, alter? 
vary, or go wrong of themselves: they must follow as they are 
ruled or directed, as much as must the operations of chemistry 
follow the master hand of him, the Berzelius, who directs them. 
They follow, they do not lead; they maintain the visibly acting 
machine; as it is formed through chemical affinity, and disposed 
by mechanical laws: but they maintain it under the immediate 
direction of the nervous system, the agent of Life; as, by that 
power which first disposed the whole, they were placed in im- 
mediate subordination to it. And even when chemical and fo- 
reign agents interfere with the usual chemical actions of this 
laboratory, it is on and through this system that they must and 
do act. They derange it; and it causes, or suffers the chemical 
actions which it used to regulate to right, to go wrong. Thus 
it produces disease, even when we assume from partial evidence, 
that the seat and pure cause of such disease is elsewhere, in the 
machine, or in the laboratory, while, thus, much more, does it 
produce that in other cases. The Directing Power or, force is 
deranged or disturbed; the chemical actions are deranged; the 
machine is deranged. This is the train; and invert it as we 
may, by commencing from either secondary consequence, still 
we must revert to the prime mover, and recommence the train 
in its due order, or view the nervous system as the fundamen- 
tal seat of disease; the cause of wrong actions in its subordi- 
nates. 

Let those who can and will meditate on this subject, consider 
it; I dare not here go deeper into that which is a question for 
physiology at large. But let him who will thus meditate on 
this, and will also ask himself what he has hitherto considered 
the animal living machine to be, learn to think of chemistry 
also far otherwise than he has ever yet done; far otherwise than 
as Physic knows that science or thinks of it; while I shall not 
assert what is not true, when I say that whatever the ostensible 
fact or the belief may be, this does not form a real branch of 
medical education: being not merely unknown or neglected as 
a philosophical science, as the Great Science, but unknown by 
the great body of medical practitioners, I might almost say, by 
the general body, even in its most ordinary and almost empirical 
details. Had it been otherwise at present, had it ever been 
otherwise since the very commencement of physic, we might 
not indeed have been now really acquainted with physiology, 
but we should at least have avoided the endless chaos of clumsy 
hypothesis and wordy nonsense with which physic has over- 
whelmed the world. 

And let him who thinks of chemistry, contemplate it as the 
science of that power by which, not only the animal machine is 



MARSH FEVER AND NEURALGIA. 448 

med, and preserved, and acts, but of that power which formed 
the very world itself, which preserves, as it formed, all that the 
universe contains, animate and inanimate, which is the cause of 
all action, the agent and first mover — under that Higher Power 
which direct the Universe — of every action, every motion, eve- 
ry change, every destruction and every renewal, which takes 
place on and in the globe which we inhabit. This is chemis- 
try: it is the Great Secondary cause, the right band of The Di- 
vinity on Earth, the unseen agent by which His laws or ordi- 
nances are carried into execution, and, to our apprehension, ap- 
pearing to partake of a spiritual essence, to be the immediate 
emanation of the Soul of the Universe, of the Deity. And 
thus is the animal machine under its laws; while these are here 
directed by that ulterior structure, the nervous system, to which 
the Deity has attached the principle of Life, and through which 
the Soul of man is enabled to act on matter and to be affected 
by it. 

We are ignorant indeed how the nerves are constructed, and 
how they act in performing their almost miraculous offices; we 
therefore shut our eyes to them, as if to avoid our own re- 
proaches: we do not know consequently in what way they can 
be diseased; and, not knowing this, not knowing how to exa- 
mine their pathology, any more than their physiology, by dis- 
section, nor how to reason respecting it from physiological prin- 
ciples and analogies, physic seems almost to have agreed in be- 
lieving that they were not subject to disease or derangement, of 
their own, independently; and to have contented itself with 
labouring at what was least apparently difficult; wasting its cen- 
turies in making just the progress that might have been expect- 
ed from such a mode of investigation. 

This cannot be the right road: yet if we are still ignorant of 
the structure of the nerves, and of the mode in which they ex- 
ecute their functions, it surely has at least been demonstrated 
that they are subject to diseases purely their own; derangement 
of structure or of function; derangement in some mode, pro- 
ductive of peculiar symptoms and peculiar diseases. This is 
what the subjects of the preceding essay have demonstrated, al- 
most as nearly as any thing is demonstrated in physic; though, 
still, the pathological condition, the proximate cause, is inac- 
cessible. Neuralgia at least demonstrates, if intermittent does 
not so perfectly, that the nerves, or a nerve, can be deranged, 
and can produce a peculiar disease; and that this disease is as far 
independent of the rest of the body, and of the circulating and 
glandular system, or of the obviously chemical department of 
the animal structure, as aught can be in a structure so compli- 
cated and mutually dependent; while, when that appears to be 
engaged, it is engaged as a collateral effect, not as a cause, though 
as an effect capable, probably, of becoming a cause of the second 
order in the production of further diseasi 



444 .-VATE OF THE NERVES IS- 

Thus must I view Neuralgia at least, and probably intermit 
tent also, as a disease of the nerves or of the nervous system" 
and in spite of the popular and false meaning of those terms 9 
thus must I continue to speak of them as far as I have any re- 
marks to offer; while still convinced that whatever I say will 
not produce the effect which I desire, against the weight and 
influence of those perverted terms; and that, moreover, and as 
an accessary consequence, in the popular feeling, the more com° 
pletely I may succeed in proving intermittent and neuralgic dis- 
eases to be nervous, so much the more certainly will contempt 
be thrown on them and on those who labour under their visita= 
tions. 

Let it now be admitted that the nerves themselves can be dis- 
eased, originally, in their own structure and functions, and we 
may then examine, if still very partially how these several dis° 
eases are produced and related. Did we know what that de- 
rangement was, we should be possessed of the proximate cause 5 
and the whole task might be easily completed. They who are 
satisfied with hypothesis would be at no loss in contriving a 
term, or might perhaps borrow spasm or inflammation, since 
these^form the great " open sesames" of all physic: an alge- 
braist would substitute the unknown quantity x, and reason on 
it as far as his materials would lead him: and this is the rational 
and philosophical mode. 

Yet the materials themselves are very limited; I must make 
the best use of them that I can. And to avoid circumlocutions^ 
since either I must do this, or coin new terms, or adopt old ones, 
misleading certainly by means of the last, and probably pro- 
ducing confusion and error by either expedient, let me be per- 
mitted, like the algebraist, to take x as the condition of the ner- 
vous system in intermittent, and y as the local affection of a 
nerve in Neuralgia; to which I shall also have occasion to add 
z, as representing the equally unknown condition which pro- 
duces palsy; and hereafter also, as I conceive unavoidable, w*, 
as the symbol of that inflammation, connected with Neuralgia 
and intermittent, which must differ from phlegmasia or common 
inflammation, and which I trust I have already proved to be es- 
sentially different in pathological character, however similar to 
the senses. The reason for adopting such a symbol here, is per- 
haps even more important; as I hope soon to show. 

This is not a piece of algebraic affectation; since it is impos- 
sible to reason without a symbol of some kind, and we cannot 
apply terms expressive of ideas, before we are possessed of the 
ideas themselves. When the value of x, y, and z, and of iv 
also, though a remoter condition, or more properly an effect than 
a cause, shall hereafter be discovered by physiologists, it will be 
easy to give a better form to these remarks, and to do much 
more as to the whole of this subject than I can at present even 
conjecture. 



MARSH FEVER AND NEURALGIA; 445 

To take the simplest Neuralgia, and it may be that of the 
face; the Tic. In this, a certain portion of a nerve is in that 
condition which is here termed y, and which is ascertained to 
be brought on by Malaria acting on the body, or by the local 
application of cold, apparently, or lastly and more rarely, by 
Injuries, even by those of a distant portion of the same nerve. 
That the disease belongs to the body of the nerve itself, seems 
proved by this latter fact, as it is, further, by the symptoms 
themselves; since the effects do not necessarily extend beyond 
it. And the obvious consequences, or sensible effects, are, in 
the purer cases, pain, simply, in what must be supposed the es- 
pecially diseased part; regulated, very mysteriously, in its re- 
turns, by a period of twelve hours, or by its multiples, or sub- 
multiple? while there is an interval without obvious disease. 

It is probable, however, that the condition y is a permanent 
one, however subject to intervals of ease, among paroxysms 
producing pain: a concl on derived from the fact of the regu- 
lar return of the pain f - | ^xact part, even through the years 
of a long life, and conn in some cases, by tangible disor- 

ganization. But here are »ve stopped; or we have not yet dis- 
covered what is the pathological condition to which the term y 
is annexed. The dissections that have been made have thrown 
no real light on it, if we except that thickening of the coat or 
connecting medium of the proper nervous fibres which produces 
the tumour described in a former account of the disease; while 
we cannot suppose the proper disorder to lie in that which ap- 
pears to be merely an appendage to the sensible part. 

And as far as dissections can deserve credit, these deserve 
it; since they have been performed by the most able anatomists, 
among whom I need only name Bichat and Charles Bell; while 
that they have thrown no light on the subject, is testified by 
the reporters themselves. The former, in a tumour of this na- 
ture, found varicose veins leading into the sciatic nerve; the 
latter, and many besides him, nothing but that coagulated lymph 
or almost inorganic matter which belongs, as a diseased state, to 
the interstitial membrane; the best marked swellings having the 
same appearance which occurs in the ends of nerves that have 
suffered in amputation. 

This condition of the nerve under Neuralgia has been called 
a state of inflammation; but while that is a favourite term, ap- 
plied to solve far more than it can explain, we cannot under- 
stand an inflammation, or a phlegmasia, alternately active and 
dormant, and through such a length of time; and can with 
difficulty believe that to be a state of true inflammation, at any 
time, which is not relieved by local or general blood-letting, 
which, on the contrary, is aggravated by those proceedings, and 
which, when it is cured, is removed by a system of remedies 
admitted to be injurious in inflammation. 



446 STATE OP THE NERVES IN 

If, however* there is a real inflammation present at times, or 
in certain eases, as indeed cannot fail to be the fact from the pro- 
duction of this effused and coagulated lymph, we can easily ex- 
plain that on the principles formerly brought forward. In va- 
rious modes of the disease, there is inflammatory action or ab- 
solute inflammation produced, as a secondary effect, in the ad- 
joining parts, as, very notedly, in the toothach and the ophthal- 
mia: and while it is easy to understand how this should also 
happen in the membranes which include the nerve, it becomes 
more obvious than before, that this is but an accessory effect, and 
not the disease itself; and that they, consequently, who have 
considered and treated Neuralgia, in any case, as the inflamma- 
tion of a nerve, have committed a radical, if an easy error. And 
this inflammation, it is plain, may be permanent, just as the oph- 
thalmia or the rheumatism of the face is, while the condition of 
the nerve giving rise to it is periodical and transitory. Admit- 
ting, consequently, that the nerve is inflamed in Neuralgia, there 
is a cause beyond that, or a prior morbid state, which is the cause 
or condition y, sought. 

Let us now inquire what happens in cases less simple; while 
it is indeed uncertain whether, except in the instance of local in- 
jury, there is such an abstract case as that which I have, for the 
sake of simplicity, stated; or whether the local condition y is 
not almost necessarily connected with a general disease of the 
nervous system, here to be distinguished, for want of knowing 
its nature, by the symbol x. 

The condition y being present, it is attended by a febrile state, 
generally paroxysmal, accompanying the painful stage of y, 
ceasing similarly, and similarly regulated in its returns by the 
period of twelve hours or its multiples. This is intermittent 
fever; the symbol x representing the unknown state of the ner- 
vous system in this disorder. How far that state extends, pri- 
marily, through this system, we cannot certainly know; but that 
the brain itself is in that condition, is proved by all the pheno- 
mena of these diseases; while the general system of the nerves 
beyond that, (always excepting the one in the condition y) may 
be affected inasmuch as they are so, only through the influence 
of the brain. 

Practically then, in Neuralgia, we must consider the condi- 
tion to be, generally, x-\-y; or there is a permanent disease pre- 
sent in the nervous system or in the Brain, subject to alternate 
activity and rest, or of action and inaction, as far as our senses 
can discover, united to a similarly intermitting but permanent 
disease in an individual nerve. It appears therefore that while 
the condition x may, and very often does, exist without y, the 
latter cannot so well exist without the former; or the general state 
producing intermittent fever may or may not be united to the 
local one producing Neuralgia, while it is less common, reverse- 



MARSH FEVER AND NEURALGIA, 447 

Iy, to find y unconnected with x, or Neuralgia independent of 
intermittent. 

1 am far from deciding, however, how this fact absolutely 
stands: though, if I have not seen such a state of things, I can 
conceive a periodical Neuralgia existing without an accompany- 
ing periodical fever. I mean here, of course, on the supposi- 
tion that the disease has been produced by general causes acting 
on the system, and not by local injury. In this latter case, we 
can at least easily suppose that y exists alone, whether this shall 
prove the fact or not. But it is a point that I cannot determine, 
for want of sufficient experience, or for want of facts, and which 
must be left for future examination: while, in the mean time, it 
is rather indifferent as to the present investigation, how it shall 
be finally determined. 

Further, while the same cause produces both x and y, or x-\-y? 
there are other connexions between these two conditions, to be 
considered, respectively, general and local, which deserve a 
briefer analysis under this formula than I could bestow on them 
in the former and descriptive portion of this essay. The active 
state of the condition x is found to alternate with that of x-\-y? 
under the usual law of twelve and its multiples: or the condi- 
tion x, after some duration, is converted into x~{-y, or, reverse- 
ly, x+y is converted into x, or the two alternate, by relapses 
or periods, in various modes: while, further, y appears some- 
times to become the substitute of x to a considerable extent, or 
perhaps entirely; or, as the local disease gains in intensity, the 
general one diminishes, or else the latter may be exchanged for 
the former. 

And in any case of the problem, or equation, x-\-y producing 
Neuralgia, x may be a variable quantity while y is a constant 
one; or it is an exhaustible term in this equation. In strictness" 
therefore, under this symbolical form, a different mode of alge- 
braic expression would have been necessary: but while this 
would really give an air of affectation to the whole, it must be 
remembered that such formulae are not intelligible to those who 
will find no difficulty in following this reasoning under a simpler 
mode of exnrossion. And it is sufficient that the reader has, 
once for ail, oeen reminded of it. 

All these circumstances argue, if not a similarity, a strong 
analogy or intimate connexion between the two conditions a?, y 9 
or between the general disease of the brain and the local on. 
the nerve; while that similarity is strengthened by the fact, that 
the same remote or original causes produce both diseases, and 
that both are cured by the same remedies, and aggravated by 
the same maltreatment. To use a common lax phrase in phy- 
sic, we' might conceive that while x, or the proximate cause of 
Intermittent fever, was a general disease of the nervous syst 
x -\-y was the same disease with a local determination: as w 



44S STATE OP THE NERVES 13? 

might suppose that where y is present, and x not assignable, the 
case was in the same order of analogy as that of a local phlegr 
masia produced by unassignable inflammatory diathesis; to use 
the same current phraseology. 

From these considerations we might conclude, notwithstand- 
ing our ignorance of the proximate cause, or of the values of x 
and y, that the Intermittent fever was a disease of the Nervous 
system, or of the Brain, essentially, and that whatever symp- 
toms, collateral or essential, occurred in it, were secondary ef- 
fects, as were all the anomalous diseases which I have pointed 
out under this general head. And therefore also, that as far as 
the circulating system was affected, all its affections were of a 
secondary nature; a conclusion of great importance as to the 
practice, since the original cause x ought here to be the chief 
object of our attention. And as, from the symptoms, from the 
nature of the useful remedies and the effects of the injurious 
ones, as well as from the nature of these last, the state x appears 
to be connected with all those symptoms or consequences which 
mark what is esteemed debility in the system, while there are 
other inflammatory conditions or diseases, which indicate, in all 
the same modes, a state exactly the reverse, the distinction in 
question becomes most important; while it points out, in a ge- 
neral way, the reason, or rather confirms the reality, of what 
has long been admitted from practical observation; the existence 
of two inflammations at least, of extremely opposed characters. 

I must now pursue the connexion between x and y further, 
so as to examine into this particular consequence, Inflammation; 
the inflammation of Intermittent and Neuralgia. The general 
facts relating to it have preceded, as have the proofs: but while 
the distinction between what I here represent by the symbol w y 
and inflammation in its ordinary sense, is most important in 
practice, so is it necessary that the general reasoning should be 
brought together in that narrow manner which was not former- 
ly practicable. Yet it will be remembered that w stands, or may 
stand, in somewhat a different relation to x than does y; since 
if it is a dependence of x, directly, so is it a dependence of y, 
even in those cases where y might be conceived to follow x, as 
well as where it may be imagined primary; being therefore, if 
this be the fact, at times the third effect, or the effect of an ef- 
fect. And I may here take y simply as the symbol, instead of 
x+y, that being no further necessary: and, since the former is 
an unequal or varying quantity or force, becoming evanescent, 
as I just remarked, while the other remains, the compound sym- 
bol, thus simply stated to prevent the necessity of adopting a 
much less generally intelligible algebraical expression, might 
tend to mislead. 

The condition y, therefore, possesses the power of inducing, 
apparently through the minuter ramifications of the affected 



MARSH FEVER AND NEURALGIA, 449 

nerve, an exeited circulation, or an inflammatory tendency, in 
the neighbouring vessels, with increase of sensibility; and this, 
in some instances, proceeds to a species of apparently active and 
permanent inflammation. Or, let it be supposed that it is the 
condition x which produces this local effect, as it produces y f 
the conclusions to follow will not vary essentially. 

In the condition x, or, intermittent fever being present, we 
find that while any one principal nerve may suffer the state y, 
so do there arise diseases without pungent or proper neuralgic 
pain; being among the anomalous symptoms or cases of inter- 
mittent which I have described as far as I am acquainted with 
them. Now the reason for supposing that these depend on the 
condition y in the nerves supplying these parts, will be imme- 
diately given; and if they be admitted, then we must, theore- 
tically, look on all these as secondary diseases or symptoms of 
intermittent. Or otherwise, if they depend on x, as y does, 
being either conditions or modes of y, or else are thus produced 
through the intervention of y, so, further, the condition y being 
probably at times, sole, or independent of x, may they be modes 
of y in the same independence, or else effects of that state as 
existing in an independent manner, the produce of the exciting 
cause. Or, in terms, the inflammation in question, here called 
w, may depend on pure intermittent alone, or on neuralgic in- 
termittent, or on pure Neuralgia; the intermediate case being 
that already alluded to where iv may be a third concatenated 
effect 

And in these cases, the diseases which are consequential, or 
the effects, will vary according to the nature and offices of the 
affected parts: so that w being the fundamental effect, or the pe- 
culiar inflammation, there may be produced pleurisy, rheuma- 
tism, gastritis, ophthalmia, or whatever else; simulating, in cer- 
tain cases, the disorders of the same visible aspect or general 
symptoms which arise from another, and apparently very op- 
posed cause. Such is a theoretical and abstract view of a gene- 
ric disease: and if it is the general expression of what has pre- 
ceded on this particular subject, it is confirmed by the various 
facts found in the preceding description of these disorders, on 
which it has been founded, or from which it is generalized. To 
proceed to the promised illustrations and reasons. 

If the sciatic nerve be the seat of y, the pain is highly 
marked, as it is when any other principal nerve is similarly af- 
fected. In the lumbago of the same character, the disease be- 
ing apparently seated in the smaller ramifications of the cauda 
equina, the pain is more general and less acute; and it is still 
more mild and more diffused in hemicrania, in the similar af- 
fections of the rectum and bladder, and in the rheumatic pain of 
the face without fixed inflammation. There is a gradation there- 
fore in the quality of the pain, proportioned to the sizes, and 

37 



450 STATE OF THE NERVES IS 

numbers also, of the nerves affected y; and that, in these cases, 
this is the affection, is proved by the same facts which prove it 
in the simplest Neuralgia with which I commenced this exami- 
nation. 

This is the first gradation; while in it I might perhaps have 
included the palpitation of the heart; an affection of its motive 
nerves, incapable of producing pain, inasmuch probably as that 
organ possesses few or no nerves of mere sensation, and exert- 
ing itself in another manner. 

This is the basis, or the first step, in the chain of the argu- 
ment. The smaller nerves may be excited to action, or may 
be, in whatever manner, in the state y: and that state does not 
produce proper neuralgic pain, either because it is moderate in 
degree, or because the affected branches may be minute; while, 
when existing, it is diffused, as occupying many nerves instead 
of one point. 

The second step is no less plain, and no less proved. The 
nerves, thus in the state y, may be the secretory nerves of glan- 
dular vessels. The consequence which would be inferred' does 
occur. It is a state, in these vessels, of activity; and the result 
is increase of secretion. It may be thus, simply: it may be at- 
tended with pain; and that pain may either be neuralgic, or it 
may be the pain of temporary, and modified, or imperfect in- 
flammation: of an action in the secretory arteries, greater in 
degree, or, possibly, of an analogous action in non-secreting ar- 
teries. Here then is y, not properly painful, or seldom so, but 
exciting; undue action in the minute vessels. 

The next or third stage, bringing us a degree nearer to sim- 
ple inflammation, is that state of increased sensibility, proceed- 
ing gradually to turgescence or enlargement, and to redness, 
which happens in a fit of common Neuralgia: the y of the nerve 
here producing, probably through its influence on the minuter 
branches, and by means of them on the minute arteries, an in- 
crease of action tending towards inflammation, but which ceases 
with the cessation of the active state of y. 

The fourth step occurs, demonstrably, in rheumatic affections 
of the face or other parts, with Neuralgia or intermittent; with 
either x 9 or y, or x-j- y, and in cases where the disorder is tran- 
sitory or periodical. The condition of action in the minute ves- 
sels has increased: there is impending inflammation, or an ap- 
proximation to it: x or y are about to produce w. Or there is 
an actual w, which ceases with the action of that mysterious 
cause, in x or y, by which they are under the periodical law of 
twelve hours. In the external parts, those inflammations w are 
visible and indisputable: they are inferred of the internal ones, 
in sundry cases to which I have formerly referred. When y is 
present, alone, or otherwise, the dependence is proved by their 
coexistence: as it is inferred that w is the dependent, from what 



MA&SH EEVER AND NEURALGIA, 451 

has preceded. When x alone is present, it is inferred to be the 
cause, from the similarly periodical and consequential nature of 
the to, and from the effects of remedies, for good and evil. 

The last stage is the point to be proved. The inflammation 
is perfect: but it is a perfect iv, as in the ophthalmia of y and 
x. In this particular case, it is visible and indisputable: it must 
be, and can be, inferred from symptoms, when it is not to be 
seen from the invisibility of its place; as it is also from dissec- 
tion. And it is still w: because, if it were not, at what point 
does the character change to the reverse one? because, even 
then, its y will accompany, in regulated periods or otherwise; 
as will its x, or both: because, even then, it is subjected to pe- 
riods during one portion of its progress, while permanent, or irre- 
gular, in another; because, the same remedies, for good and evil, 
continue to produce the same effects as they did in every link of 
this chain from the purest y or x to the most inveterate and de- 
cided w. And if all this is the same when the inflammation is 
not visible, as it is in the ophthalmia y and x, but must be in- 
ferred from symptoms, then is it a just inference that all such 
inflammation is w, depending on x or on y; while the depend- 
ences on x are the inflammations of Marsh fever, so much mis- 
apprehended, but, still, through experience, better treated than 
they are understood. 

Thus have I traced an argument, to which I cannot see an 
answer: drawing the connexion as close as it can, now at least, 
be drawn between intermittent or Neuralgia, and inflammation. 
It is an analysis of the principal facts as well as arguments which 
have been already used in different parts of this essay, for esta- 
blishing this important point; namely, the true nature of this 
particular inflammation. And as far as relates to x, it is the 
basis of the theory of anomalous and simulating fevers of an 
inflammatory character, every one of these being a w of some 
particular part; as the other, the nervous disorders, with similar 
connexion or dependance, will find their analyses, as far as those 
are now attainable, under y, and z. 

True, it is deficient, inasmuch as we do not know what the 
condition to, physiologically, or pathologically is; or the real 
proximate cause of this particular inflammation. But it is only 
deficient as are x, y, and z, a deficiency which does not destroy 
its utility. Nor is it further deficient than is the theory of the 
reverse inflammation, or of true phlegmasia. In this, as in the 
other, all that we can see is an effect, not a cause; enlargement 
of the minute vessels, or, if this term is more pleasing, increase 
of action. This is but an effect; yet physic goes on forgetting 
that, when it calls the proximate cause of inflammation increase 
of action, it is but substituting one term for another, and that 
term the name of an effect, not of a cause. Increase of action 
is* inflammation, and inflammation i* increase of action: vet 



4"^ rB OF THE SERVES IB 

thus does physic write — not reason — through volumes in thou- 
sands, and flatters itself that it is making progress in philoso- 
phy. That two opposed conditions or causes will produce in- 
crease of action in the minute vessels, and that this action is in- 
flammation, has been proved: but, to precede and immediately 
produce that, there must be some immediately previous cause 
in those vessels, and intermediate between that effect and the 
remoter cause which lies in the nervous system. This is the 
real proximate cause, and this it is which is unknown in both 
inflammations; while, in each, it must be different. We have 
not discovered its nature, it is true; but there is a step made at 
least, when it has been shown that there is such a state yet to 
be investigated, and when the attention has been directed to the 
right point, and to facts instead of words. 

^Inasmuch as there may be more leading causes than two, of 
this effect, inflammation, and consequently, more than two pro- 
perly proximate ones, it was not my business to enter on that 
question, and I have gladly avoided it that I might not encum- 
ber further the present argument. 

I have perhaps stated all this too briefly and too abstractedly. 
It will probably be a cause of greater hesitation than any thing 
which I have attempted thus generally to deduce; and particu- 
larly because of the practical questions which it involves, and 
because of the extreme difficulty of overcoming the habits of 
thinking implicated in the term inflammation. Let me attempt 
to illustrate it further, since there cannot well be a more impor- 
tant question, from the deep share which it takes in the most 
difficult portions of this entire essay, and especially in the most 
intricate varieties of marsh fever. It involves the entire ques- 
tion of the difficult cases of remittent fever attended by inflam- 
matory affections, and of the intermittents of similar character. 
It involves also the inflammatory varieties of simulating and de- 
ceptive marsh fever, whether acute or chronic; those cases, per- 
haps the most important of all, from their peculiarly deceptive 
character, where the fever or the x is little, and the inflamma- 
tion, or the to, is chief, or all. Thus does it also involve the 
neuralgic inflammation, such as the ophthalmia, when the Neu- 
ralgia is overlooked still more; where it is either unapparent or 
is really absent as a visible disease. In the former cases, it is 
what I have sometimes called, misdirections Gf the disease, 
of the x, or localizations; and its extreme importance may 
therefore justify some further illustration, even to the hazard of 
repetition. It is the inflammator}^ misdirection or localization, 
as the other cases are the nervous ones: and perhaps, in prac- 
tice, the errors of confounding the w of x with ordinary inflam- 
mation, are even greater than those which follow from con- 
founding z with palsy and apoplexy from other causes. 

If I have succeeded in proving that the rheumatism of the 



MARSH FEVER AND NEURALGIA. 453 

face and that of the eye, are neuralgic inflammations, excited es- 
sentially by the unknown peculiar state of the nerves here called 
y, while I have also shown that similar ones, as in the local in- 
termitting rheumatism of a limb, can be produced by the condi- 
tion x; and that, in every case, this inflammation is not cured 
by evacuations, or debilitating means, but on the contrary, ag- 
gravated by them, I may safely conclude that there is an inflam- 
mation which is not a phlegmasia in the proper sense of that 
term, and I may be allowed to designate it, as I have done, by 
the symbol w; because, as occurring from mere intermittent, I 
could not with so much propriety here call it the neuralgic in- 
flammation, as I did formerly in specific cases. 

Now I have proved, that in a great number of cases besides 
these, w is a diseased state essentially different from phlegmasia, 
however resembling it to the eye, or in the symptoms of pain, 
turgescence of vessels and redness: that difference being evinced 
to us by the effects of remedies, as I have just said of the others, 
and that proof being ample; while we cannot well command 
any other equally universal, though it would also appear that 
there is often an essential difference in the terminations of the 
visible disorder. And the state iv, occurring from x and from 
y, is also acute, or violent and transitory, or else chronic, or 
mild and durable: while further, it has been proved, that whe- 
ther arising from x or from ?/, from intermittent or from Neu? 
ralgia, it is, when chronic, always aggravated by debilitating re- 
medies and cured by the reverse; just as it also is when acute. 
Or, in this latter mode, when it occurs in an external part that 
we can see, as in the eye, however acute it may be, or however 
energetic both itself and the febrile state, or the x to which it 
appertains may appear, it is, similarly and equally aggravated 
or cured, by the same relative practices; being, in this case also, 
an unquestionable w, and not a phlegmasia, however resembling 
one. 

The great question remains: whether we ought not to form 
the same conclusion as to every inflammatory affection occur- 
ring under cc, and under all conditions of that, acute as well as 
chronic, even when these are internal and invisible, characte- 
rized therefore by pain alone, or by such other well-known 
symptoms as it is unnecessary to enumerate. Thus, if this ana- 
logy and this reasoning be allowed as valid, the gastro-cnteritis, 
in all its forms, of French physic, will be w, not phlegmasia; 
just as I have already suggested that it ought to be considered 
an effect, not a cause of marsh fever, as it is supposed by that 
system. The same reasoning will also apply to the inflamma- 
tions of the brain, the pleura, the lungs, the bronchial mem- 
brane, and so forth, and even, probably, to the acute hepatitis 
of India: or these will be all w, not phlegmasia, or conditions 
of inflammation resenbling that of the neuralgic ophthalmia, 
or, if this term be preferred, rheumatic inflammations. 



454 STATE OP THE NERVES 1ST 

How important this view is, as to the practice, I need not 
now suggest; since on its truth or falsehood must the balance of 
this hang, for good or evil. And if it is supported by the ana- 
logies already pointed out, and the various views formerly stated 
at length, so is it borne out, I need scarcely say, by numerous 
observations on actual past practice in various hands, and if I 
mistake not, by the treatment of the hepatitis in India, founded 
on ample experience and against theory; the theory of phleg- 
masia. 

This is an argument on which I already laid stress in the case 
of the ophthalmia, and on a comparison of Wardrop's practice, 
derived from experience, against the ordinary theory and prac- 
tice also, with my own, deduced from theory. And while I 
cannot help regarding it, as in all philosophical proceedings, to 
be a weighty argument, I need not remind the reader of the in- 
numerable instances in the inflammatory marsh fevers, where 
the practice of acute and experienced physicians has thus, and 
in the same manner, against supposed analogy or theory, and 
practice also, deviated from the received usages and opinions; 
adopting that which I should, in the same cases, have adopted 
from my theory. I had occasion to point out these facts for- 
merly in several instances; and very particularly to show, how, 
even the French physicians, while in the act of declaring the 
existence of inflammation of the stomach and bowels as the 
very cause of fever had pronounced in favour of such a prac- 
tice as my theory directs: proving the presence of iv, where 
they decide, in words, on that of phlegmasia. 

Nor would it be difficult to point out many other facts respect- 
ing all the inflammations occurring under cc 9 as under y, in sup- 
port of the same views; among which none are more remarka- 
ble than their cessation and reproduction, often strictly periodi- 
cal, in the highly severe epidemic intermittent of hot climates 
possessing inflammatory symptoms of various kinds: a fact ne- 
ver occurring in proper and simple phlegmasia, if we except 
gout perhaps, and ranking these with that ophthalmia which I 
have shown to be not a phlegmasia, but a w. But I will not 
dwell on these further proofs, as every physician can now add 
them for himself; though I ought also to point out many ap- 
pearances on dissection; and among others, as a very remarka- 
ble fact, the frequent want or absence of the traces of an in- 
flammation which must have existed, and often, not long before 
death. 

On that point, however, let me remark, what is of great im- 
portance as to the purity of this evidence for opinions, and for 
opinions, themselves most important when erroneous; and it is, 
that inflammation is frequently said to have been present on dis- 
section, when that is not the fact. This is but a branch in a 
wide mass of error in the same proceedings, and particularly 



MARSH FEVER AND NEURALGIA. 455 

as to effusions; and as to the state of the brain; errors reflecting 
high discredit on anatomists, from their frequency, and from 
the pernicious opinions to which they have given rise, or which 
they have confirmed. The appearances, so often mistaken for 
inflammation, as well as for living effusion, are appearances 
which may occur after death, and do so occur: often sufficient- 
ly deceptive, it cannot be denied, and yet, I believe, always to 
be distinguished by a degree of care not often bestowed on an 
investigation too generally conducted in a careless manner, or 
conducted by persons willing to find what they think they have 
found, or even, under prejudice and system, concurring to their 
own errors. 

I will now terminate this particular abstract: suggesting only, 
that if what I have attempted to prove shall be admitted or es- 
tablished, it would be most useful to substitute some term for 
the symbol w, and to discard the words phlegmasia and inflam- 
mation in these cases: above all, in the latter, since it is most 
certain that as long as they shall continue to be thus misapplied, 
no reasoning nor experience will succeed in establishing a bet- 
ter practice among the multitude, guided as it ever is and will 
be, by terms, habits, and associations. 

Yet as a species of further corollary, I ought to enforce a sug- 
gestion which seems especially to demand attention, because of 
its great importance as it relates to the practice in fevers of this 
nature, and not improbably indeed in fevers, from whatever 
cause. 

It is proved that x can produce inflammation, through a mo- 
dified y, or otherwise; that such a disease is aggravated by the 
treatment of common active inflammation, and that the means 
of cure must be directed to x. Now the intermittent, and the 
remittent, are often attended, among other inflammations, by 
such or similar affections of the brain, particularly, though these 
last are often also suspected where they probably do not exist 
The important question is, whether these are not always of 
the same class of inflammations, w inflammations produced by 
x; while I cannot help expecting that when the present fashion 
of considering the great mass of inflammatory affections to be 
of the same nature as those, the ordinary ones, of the pleura 
and bowels, or true phlegmasiae, has subsided, or when the ha- 
bit of viewing inflammation, as of one character only, shall be 
calmly reviewed together with what has been stated in these 
pages, physicians will find it necessary to review their practice in 
the cases to which I allude, and in these very particularly. And 
before I terminate this branch of the present general view, let mc 
make one remark, which ought to have been more urged in the 
preceding part of this work than it was. This relates to what 
is popularly called a Coup dc Solid. How often the action of 
the sun on the head may produce veal inflammation of the brain. 



456 STATE OF THE NERVES IN 

or true phrenitis, I cannot, for want of the requisite experience 
in hot climates, decide; yet this I can say without hesitation, 
that out of numerous carefully reported histories of that sup- 
posed disease, I have found none which was not, simply, the 
remittent fever of those climates, excited by the ordinary causes; 
while a casual exposure to a high sun, or the mere popular opi- 
nion and theory, had been the ground -work of the false judg- 
ment. I need not again remark how symptoms may appear to 
justify that, nor how important the truth is as it relates to the 
practice. 

To return to pure intermittent, for the purpose of examining 
the condition z. If what T have said tends to prove that this 
disease is an original derangement of the nervous system at 
large, or possibly of the brain alone, that it is a state x of that 
system, this is confirmed, in the mode of dilemma, by the very 
fact of its connexion, of the very singular connexion which I 
have shown, with the state y; as we can conceive no other mode 
of influence which can thus be exerted on a distant nerve. This 
view is further aided by the very singular influence which in- 
termittent exerts on the nervous system at large, and on nerves 
individually, independently of the state y, or of the inflamma- 
tion which is dependent on it. As to the general nervous symp- 
toms, the state of the mind, and so forth, I need only recall 
them to the reader's memory, while I must dwell somewhat 
more particularly on those of a more active and permanent cha- 
racter. 

These are the paralytic consequences. I surely need not say 
that a nerve may lose its power, partially or generally, from a 
mere local action, entirely independent of any affection of the 
circulation, or even of the brain; since this is a common conse- 
quence of the application of lead. And thus, poisons and cold 
act more extensively, even so as to affect the entire system, or 
the brain. Now this condition of the nerves is, pathologically, 
as utterly unknown as are the conditions x and y, while for that 
reason, I must distinguish it by the symbol z. 

Supposing the cause Malaria to be applied to the body under 
certain modifications, under that of great energy probably, the 
first consequence to the brain is apoplexy, or what is in reality 
the correct term, a general palsy; or as I have also shown, it is 
sometimes a partial palsy. The former is the condition z in its 
most extensive form, and when it is perfect, the consequence is 
death: an event which I have formerly shown to occur in this 
manner. It is probably analogous to the effect of poisons; and 
it bears some resemblance to that state which follows concus- 
sion, since it is aggravated by the evacuant and debilitating sys- 
tem; so aggravated often, as to terminate in a permanent z> more 
or less general, when that would otherwise have been transitory, 
and extending even to death. 



MARSH FEVER AND NEURALGIA. 457 

All that we can say of this state is, that it is a loss of power; 
since, not knowing the cause, we must use the effect as a term; 
or it may be called, in the usual lax phraseology of physic, a 
debility of the nervous system, or of a portion of that. And 
supposing it to cease, or that the apoplexy, or general palsy, un- 
dergoes a natural cure, it is often succeeded by the intermittent; 
or, the state z terminates in that x. 

Here then is a remarkable connexion between x and 2 1 , or be- 
tween intermittent and palsy, but it is far from being the whole. 
I have formerly shown that intermittent produces palsies, in se- 
parate nerves, and in every possible gradation of energy, ex- 
tending even to hemiplegia. Thus it is a tendency of the state 
x to proceed to the state z by aggravation, as, reversely, an ori- 
ginal attack z subsides into x by alleviation. Thus, were it 
aught else than the obscure animal structure and functions which 
we were examining, we might almost conclude that x and z 
were but different degrees of one affection, or that the radical 
derangement of the nerves, the proximate cause, was, in both, 
the same, differing only in degree. And it is here also remark- 
able, that if the vague term debility be substituted for z, it is 
the result of evacuants, of all causes which are supposed to di- 
minish the nervous power, to convert x into z; as if, by aggra- 
vating a moderate debility, it converted that into an entire one. 

Further, in this case, if a nerve be long affected with the con- 
dition y, this state frequently terminates, in that part, or in all 
that lies beyond it, in z; or an inveterate Neuralgia is gradually 
converted into a palsy, as far as the influence which we may 
suppose to be that of its deranged part, extends. And further 
still, it is the effect of the evacuant system, to determine, ag- 
gravate, or accelerate, this effect, as also to render permanent 
that which would have been transitory. In all these conse- 
quences, there is a very striking analogy between the proceed- 
ings of intermittent and Neuralgia, or between x and y, sepa- 
rately, as related to z; confirming still further what has been 
said respecting the analogous conditions of the nerves in both 
cases, or of the dependence, in some manner, of y upon x, and 
of % upon both. I have stated all this, on account of these ana- 
logies and of the singular connexion between intermittent and 
palsy; but if I have used the term debility, it is merely out of 
convenience, and for illustration; as it would be to adopt a very 
bad logic, though it is the too common logic of physic, to sup- 
pose that any light was to be thrown on an inquiry by using an 
effect as a cause. Debility of a nerve is palsy, and palsy is an 
effect; but thus it is that medical reasonings commonly wander 
round in circles, ever discussing and concluding nothing. 

If all these facts bring us back to the same conclusion, viz. 
that intermittent is a disease radically and essentially seated in 
the brain or nervous system, it is an opinion supported further 

58 



4o8 STATE 0* THE NERVES IN 

hy the effect of mental operations in its cure; which, however? 
cannot be discussed to any purpose as long as we are entirely 
ignorant of the nature of the connexion between the brain as an 
organic structure and the mind as a metaphysical entity. 

But there are also some other facts which deserve here to be 
recalled to the reader's recollection: since if they do not pro- 
duce any very accurate illustrations, they tend to some connex- 
ions which further discoveries may render of importance. 

I have shown that fatuity, or diminution of the intellectual 
faculties, and that even mania, are the produce of intermittent, 
and equally of Neuralgia; though it is here scarcely necessary 
to distinguish these two cases, if what I have already proved re- 
specting their community is admitted, as it now can scarcely fail 
to be. And further, that when this would not probably natu- 
rally follow, it is caused directly by the evacuant system. Or, 
that state of x which under similar circumstances, might termi- 
nate in z, producing common palsy, resolves itself, or is aggra- 
vated, into an affection which may be considered perhaps as a 
palsy in the brain itself, rather than in the nerves of motion and 
sensation; or a z of some, or all, of those parts of the brain 
which are the organs of the metaphysical mind. Here, fatuity, 
and also mania, is the produce of some state which, again, may 
be called a debility, or diminution, of the nervous energy, as it 
is produced by debilitating causes acting on the previous condi- 
tion x; that debility, however, being seated in a different por- 
tion of the nervous system from what it is in palsy. 

Those who are inclined to speculate on the division of the 
mental functions of the brain, might also, if they pleased, here 
suppose, that in the separate production of fatuity and mania, 
the local affections varied, as well in place and in extent as in 
intensity, just as they do in palsies of the limbs; thus account- 
ing for these separate and varying effects. And how far the 
noted hypochondriasis of intermittent, and its delirium, must 
be connected with these circumstances, it is superfluous to in- 
sinuate; since, on that subject, I could but vary terms without 
adding information. Others also may, if they please, trace such 
analogies as they can find, (and they are tolerably obvious,) be- 
tween these mental affections and their causes, in this case, and 
those instances of fatuity, mania, or whatever else of an analo- 
gous nature, which are produced by various causes, called debi- 
litating; as they may also speculate respecting the evil effects of 
•remedies of this character in ordinary mania arising from causes 
yet unknown to us. 

I might indeed pursue the whole subject much further; since, 
according to the usual manner of medical discussions, there is 
here matter for a treatise; but having drawn all the inferences 
which the facts seem to warrant, as far as they are connected 
with the case which I have undertaken to illustrate, I gladly 



MARSH *£VER ANI» ^ilURALGlA, 

quit it, leaving it to those who may find more pleasure, or fancy 
more advantages than myself, in speculation and phraseology. 
Whether dissection and experiment, investigations anatomical 
and physiological, will ever assign the values of x 9 y, and z y or 
discover what the condition of the brain and the nerves is in in- 
termittent, in Neuralgia, and in palsy, I cannot foresee, far as 
we are at present from even the most superficial knowledge of 
those organs and their functions, beyond their mere distribution 
and forms; but even without this, without even the slightest 
conjecture respecting the proximate cause, the preceding investi- 
gation will not be useless. 

There is however yet one remark that I must make, or rather 
renew in a condensed form, in this place, respecting the condi- 
tion z, in the nerves, or that derangement which is the cause of 
palsy. It may become important as far as the practice in this 
disease, from whatever cause arising, is concerned. It has been 
shown that this state may occur in a single nerve, or in a 
greater number, to the extent of paraplegia or hemiplegia, 
and further^ that these conditions may extend so much wider as 
to affect the brain, producing epilepsy, producing fatuity more 
or less perfect, and producing mania. It has also been shown, 
that entire apoplexy, or rather universal, if temporary palsy, 
may occur from causes of the same nature, or under the same 
circumstances; as also that epilepsy, fatuity in various degrees, 
and mania, may be produced, in these circumstances and from 
these causes, without accompanying palsy. That is, the con- 
dition z may occur in one nerve of sensation or of motion, or 
of both, or in a greater number, to the extent of one half of 
these; or else affecting these, it may also involve the brain as 
far as this is the organ of mind; or lastly, it may occur in the 
brain alone where it is the organ of the mind, affecting its pow- 
ers or faculties generally, by reduction of their energy, or par- 
tially, by destroying the usual and sound balance of those powers. 

Now, in every one of these cases, we trace an intimate con- 
nexion between the condition z, and that condition x, or be- 
tween all these enumerated disorders and the condition produc- 
tive of intermittent fever; further proving, that whatever the 
condition y, or the derangement of one nerve, can effect by ag- 
gravation or consequence, is also produced by x as to any or all 
the nerves, or the brain itself. But it is also proved that every 
one of these disorders is produced without any previous neces- 
sary affection of the circulating system, without any derange- 
ment of the circulation, as that affects the head, and by the di- 
rect action of a cause productive of intermittent fever, namely, 
Malaria, and also by mere cold, if, as to some of the effect*, 
more rarely; sometimes without the intervention of that disease, 
most commonly through it, and by aggravation or consequence. 
And further, it is most amply proved that while intermittent fe- 



4b0 STATE OT THE SERVES IN 

ver marks in numerous ways, its connexion with a state of the 
nervous system or the body, which is commonly expressed by 
the term debility, it is the effect of blood-letting especially, and 
of all other causes of debility generally, to induce the state z 3 
or to aggravate it, or to convert x into z; in other words, to 
bring on palsy, fatuity, and so forth, by acting in co-operation 
with intermittent fever. 

If it be therefore the effect of blood-letting, as it is supposed, 
to diminish the nervous power or energy, it is, in the first place 
probable, that such diminution is an essential part of the disease 
x 9 while the other conclusion is even more important, inasmuch 
as it is a practical one. It regards the extreme hazard, in the 
first place, of adopting the evacuant system in palsies, supposing 
their causes to be unknown, or it not having been ascertained 
that there is pressure on the brain, from previous apoplexy; stili 
further, the more than hazard, the certainty of injury or de- 
struction, whenever the causes of palsy are those already stated: 
while wherever palsy is a simple original disease, without pre- 
vious apoplexy, the further probability is, that this state always 
arises from the condition z in the nerves, however induced, and 
that nothing but evil can arise from the evacuant system. 

Nor is the affection of the brain or intellect any proof, in 
these cases, that this organ is diseased in consequence of a wrong 
action in the circulating system, requiring blood-letting; since 
that effect equally takes place in the palsy of intermittent fever, 
or in the z of x, as it does, notedly, from narcotic poisons and 
other causes acting immediately and solely on the nerves them- 
selves. The general caution, if no more can be remembered, 
should be this, namely, to consider the nerves as organs of 
prime, fundamental, importance, capable of diseases of their 
own, original, and utterly independent of the circulating sys- 
tem; and to recollect further, that as far as the} 7 are known to 
suffer original disease, that disease is x, y, or z, intimately con- 
nected; the last being an aggravated state of the two first, and 
each of these separately, or any two or more of them united, 
being a condition which is invariably aggravated, and often pro- 
duced by loss of blood; or, generally, by debilitating remedies: 
in brief, that as far, hitherto, as we can prove that the nervous 
system or a nerve is originally diseased, that disease is a state 
in which the system of evacuation and debility is injurious or 
ruinous. 

I must not however be understood to say that the nerves are 
not, or cannot be subject to other diseases, or even to one the 
very reverse, and demanding the very remedies which I here 
condemn. On the contrary, it is highly probable that the fact 
is so; and that increase of power or energy in nerves, or in the 
entire system, is actually a leading cause of diseases, requiring 
the opposite remedies. If it shall ever hereafter be proved that 



MARSH PEVEE AND NEURALGIA. 461 

this system, or its separate portions, can in reality undergo a 
primary diseased condition, the reverse of that which I have 
here been attempting to demonstrate, we may thus acquire a 
new mode of viewing a great portion of the diseases of the sys- 
tem; though it is plain that until we shall arrive at a knowledge 
of the nature of that condition, or the true proximate cause, we 
are still a long way from a just theory of physic; even should 
a view thus broad and vague not be without its value in prac- 
tice, as forming a species of classifications for use. It is easy 
to retort that such a view is only another mode of expressing a 
certain well-known general medical theory: but I trust that the 
connexions here traced as to one portion of it, and indeed the 
entire discussion, are of a nature to rescue it from this censure, 
since they involve facts and are not mere words; words to which 
even the inventor certainly attached no definite meaning, and 
which no one, as far as I know, has ever attempted to explain. 

A considerable number of phenomena belonging to disease, 
and belonging to different diseases, belonging also to diseases 
that have been considered of different and discordant characters, 
and to arise from separate exciting causes, and also to depend on 
different and often opposed proximate causes or conditions, have 
been collected, displayed, and balanced. Throughout these there 
has been traced, however unexpectedly to physicians, one great 
and general exciting cause, while some other such causes have 
been inferred, or admitted under want of proof, and for the 
whole equally. All these diseases have been shown to pass into 
each other, to alternate with each other, or apparently to pro- 
duce and yield to each other. All of them have been proved 
to be attended by a diminution of nervous power, from their 
phenomena, or effects: and in this there is a process of enlarge- 
ment or extension, from a minute part to the whole, as there 
has also been shown a climax, from simple debility, through va- 
rious analogous and increasing affections of the nervous system, 
upwards to Death. In all the application of powers which we 
know to be debilitating ones, aggravates, and tends to carry 
them, locally, from a part through the whole, as also to extend 
them, in point of injurious power, through the Climax to its ul- 
timate limit. And in all, the reverse powers are remedies. 
The conclusion follows: a diminution of nervous energy or 
power, the cause of disease is established. That this leading 
cause further produces iv, or inflammation which is not phleg- 
masia, has also been proved: though here the greater obscurity 
lies, because an effect, similar to all our senses, is produced by 
a condition which must be of an opposed nature, as far as wc 
can judge from the effects of remedies. 

I do not pretend to inquire what that reverse state is, not 
even to say that there is such a reverse condition of the nervous 
power, and that it is the cause of this inflammation, or even a 



4ti2 bTATE OP THE NERVES IN 

leading cause of disease. The whole is left for the future in- 
quiries of physic; as it is left to inquire what further fundamen- 
tal or proximate causes of disease there may be. But what I 
have here said in this summing up, will at least show that the 
theory, as far as it has ventured to go, is not an a priori hypo- 
thesis, and that it was not derived from a term once in vogue; 
but that it is a deduction, be it wrong or right, attained in a very 
different way; gradually brought out, through the legitimate 
road of facts, and by attempting to trace those facts to the ner- 
vous system. My line of investigation has however led me to 
examine that one condition only, its want of energy or its debi- 
lity: and it is in attempting to prove that the loss of obvious 
power was the loss of concealed or unknown causes of power, 
and that, to diminish this still further, was injurious, that I have 
come to a conclusion which is, however, but a suggestion, and 
offered as such; open to any evidence and argument that can be 
opposed to it; while, considering nothing worthy of pursuit but 
Truth, I am indifferent whence or from whom that shall come. 

There is yet a circumstance, however, if I am not much mis- 
taken, connected with this subject, which I cannot pass without 
notice, as it seems to me to present some illustration, however 
slender, of the condition of the nerves in these cases; possibly 
to give ground to some conjectures, though vague enough,- as to 
the nature of their disordered action. I must regret that the 
observations to which I have alluded are confined; but had they 
even been less numerous, it would have been my duty to point 
out the fact, as a subject of future inquiry to those who may 
have the means of examination into what, at the very least, is 
an object of physiological curiosity. 

It is familiar to every one. that by pressing on the course of 
a nerve, the parts which it supplies are benumbed; the sensibi- 
lity is diminished for a time, and the power of the muscles 
weakened or entirely suspended. It would be, as it has been, 
a natural conclusion, that they did transmit a fluid, like blood- 
vessels, and that its flow had been thus interrupted; but unfor- 
tunately this supposition is not borne out by any other facts, as 
they are not tubes, and do not contain a fluid, as far as we can 
discover. If the pressure has been slight, the power is soon 
recovered, yet not without an effort productive of very well 
known painful sensations: if very considerable or long conti- 
nued, it has occasionally happened that a palsy has been pro- 
duced, of considerable duration, and in some cases permanent. 

Whatever be the central force in this case, we may at least 
conclude without hazard, that there is such a force, and that it 
is by means of its action above the deranged conductor, that the 
temporary obstruction is overcome. And thus, also, w T e might 
infer a priori, that the facility with which that is overcome, 
and the power restored, will., in any case, and supposing the 



MARSH FEVER AND NEURALGIA. 463 

quantity of injury or obstruction given, depend on the power 
or activity of that central force, or in a similar energy in the 
conductor itself, or on both united. This, it must be admitted, 
is but vague language, yet it is the best that we can command, 
in the present state of our knowledge of this obscure subject, 
the nervous power and system: and still, vague as it is, while I 
must use it in drawing the comparison which I have here in 
view, it is a general expression which may hereafter become of 
some importance, like the algebraic symbols here adopted, when 
the value of those symbols shall be assigned; if indeed that 
shall ever happen. 

Now the fact in question is this; that in subjects, or patients 
tvhere the nervous S3^stem has suffered severely from the persist- 
ence or repetition of long continued intermittents, a slender or 
moderate pressure on any of the usually accessible nerves, or on 
those most likely, in our common actions, to suffer this obstruc- 
tion, produces the numbness or temporary paralysis in question, 
with a facility unknown to those whose nervous system is in a 
sound state, or has not been thus affected; and also, that in such 
subjects, from any given pressure, the ensuing numbness is much 
more severe and durable than in a healthy person. Or, to state 
the fact in the general terms just enunciated, the power of the 
central force, or possibly of the conductor itself, or of both uni- 
ted, is affected in a subject whose nervous system has been sub- 
jected to long-continued intermittent; or it acts with less energy 
in removing such injury, or in restoring, (if I may adopt a 
term which I use as a metaphorical one,) the circulation through 
the obstructed vessels. It is, to use this illustration again, as if 
we were to compare the efforts of the heart in a vigorous and 
in a debilitated subject, towards the restoration of the natural 
heat in a chilled limb, or the recalling of life after fainting. 

As to the fact itself, it is a natural objection that it cannot 
be very easy to observe; nor should I have ventured to state 
it, had it not often come before me, and, in some cases, in a 
very marked manner; while from having forced itself on my 
observation as a naked and a mere fact, long before I had 
thought of associating it with any of the analogous ones which 
I have detailed in this essay, or of referring these diseases 
to a pure affection of the nervous system, I feel the more 
confidence in its truth. It was unbiassed by any previous views 
or reasonings, and was not recollected for use until long after 
the opinions which prevail throughout this essay had been ar- 
ranged, and the very essay itself completed. And while I 
have observed it in various degrees in different subjects, the pa- 
tients themselves having pointed it out as an object of complaint, 
and without previous suggestion, 1 may also name one case of a 
severe chronic intermittent, in which this tendency, or this de* 
bility of the nervous energy, as I may, without proposing any 



464 STATE OP THE NERVES IN r 

hypothesis, consider it, was so great and so extensive, that tha 
patient could scarcely discover any sitting posture without suf- 
fering from it; while for many weeks during his confinement 
to bed, he could only avoid the hazard, or rather the certainty, 
of this accident in his legs and arms, but more particularly in 
the latter, by lying and sleeping on his back, with all his limbs 
extended widely. And in a similar case, there is a patient now 
before me, a long sufferer from relapsing intermittents, who, 
though long since freed from that disease, is unable to lie on his 
sides, or never, at least, without some peculiar contrivances in 
the arrangement of his bed, from the certainty of producing the 
numbness of the arm beneath, even where the actual pressure 
seems nothing, and in positions where a healthy person would 
suffer no inconvenience. Similarly, in another such patient, 
whose occupation leads to the necessary use of scissors, it re- 
quires great care to avoid the pressure of the bow on the nerves 
of the fingers employed; a casual and careless effort of this kind 
having frequently produced a tingling and numbness at the ex- 
tremity of the injured member, not subsiding for many weeks 
after. 

If this consequence occurs, during or after intermittents 
where no particular local affection or tendency has existed, it is 
probably much more frequent, and certainly much more easy 
to observe, in the neuralgic cases. In many instances of this 
nature, as well after the entire cure of the disease as during its 
existence, I have found that the deranged nerve continued thus 
enfeebled, if I may use this term, and even through its whole 
accessible extent; though, as is the case in this disorder, the 
pained part had been very minute, and situated also at its remote 
extremity. Thus for example, where the Neuralgia is seated in 
a finger or has formerly existed there, I have found, that, even 
for many years after a complete cure, a slight pressure on the 
trunks of the nerves, even as high as the armpit, was sufficient 
to benumb the limb; an effect which, from such a cause, would 
not have taken place in a healthy subject. 

As I commenced by remarking, therefore, it would seem as 
if in the intermittent, under any of its modes, whether general 
or local, the nervous energy was diminished; or that if we con- 
ceive the power of the brain as to sensation and effort, to resem- 
ble that of the heart as to circulation, it was an effect, or a cause 
— a condition is the safer term to use — in this disease, that the 
vigour of the central force or original power should be dimi- 
nished; or possibly that the power of the conductors alone, if 
indeed they are merely conductors, should be enfeebled; though 
we may equally suppose that both circumstances are united and 
coexistent. The facts that I have related seem to offer a species 
of proof on this point, which may be considered mechanical, 
or viewed as experimental: as if we could take possession of a 



MAHSH FEVER AND NEURALGIA- 465 

single nerve, and by a regulated application of compressing force, 
ascertain the strength of the resistance or of the opposed action 
in surmounting opposition. 

I need scarcely now suggest how this view of facts connect? 
itself with the condition of actual palsy following or accompa- 
nying intermittent, or of similar paralytic affections following 
locally the local affections of Neuralgia. This condition is the 
entire or completed loss of the nervous or central energy as to 
the part affected, or else of the conducting, or perhaps of the 
active and delegated power in the nerve itself; since we know 
not yet what the relative or actual powers of either are, or whe- 
ther, or how far, the nerves act originally by powers of their 
own, or merely dispense or circulate a force generated in a cen- 
tral and remote part. In this state of things we must conceive 
that the loss of power originating in the cause of the disease is 
complete, or approaches to that state; or it is the actual condi- 
tion z; in the case of numbness produced by a pressure slighter 
than that which would act in a healthy subject, we must sup- 
pose that there is merely a moderate state of z, or a condition 
approximating to it; a diminution of energy which a slight ad- 
dition of debilitating or injurious force is capable of converting 
into a perfect z. 

Every thing in short confirms the general theory here laid 
down, that the state of the nervous system in intermittent, or 
in the whole class of diseases produced by Malaria, is one of 
diminished power; whether that loss of energy be the -direct 
cause, and the sole one, of these diseases or not, or whether it 
is only an accessary effect, the cause of other derangement, and 
the proximate one of palsy. But Where every thing confirms 
this view of the enfeebled state of that power, not only in these 
diseases but after them, we derive from it the conclusion, not 
less derived from practice, thus reaching the same point by two 
separate roads, that it ought to be our business to avoid all causes 
or actions which may be supposed to act in a similar manner on 
the nervous system, as far as we can ascertain or conjecture what 
those are, and further exert ourselves, directly, in making use 
of all those means which may be supposed or have been found, 
to add strength to its energies. What these arc, on both sides, 
for good and evil, I need not repeat; though I may be allowed 
to remark, that by whatever road this subject has been here ex- 
amined, whether through a general, if indefinite, theory derived 
from different sets of phenomena, or through practical experi- 
ments, or through consequences, and the effects of medicine, 
the same conclusions invariably follow; all agreeing in the ha- 
zard or injury which flows from proceedings that induce or ag- 
gravate debility. 

I ought not, I presume, to terminate this chapter: w 



466 STATE OF THE NERVES IN 

quiring into the cause of the intermittent character of these dis- 
eases, as well as of their very mysterious submission to the law 
of twelve hours already noticed. I fear that both are truly mys- 
teries, and so separated from all analogies of any real value, that 
it is thoroughly fruitless, almost to bestow a thought on the sub- 
ject. Habit is a term that has been used, and it explains just 
what other vague terms always do. The revolution belonging 
to sleep has been named as an analogy; but I truly cannot see 
how it bears on the question, as long as it cannot explain the re- 
currence of tertian and quartan. We can scarcely conjecture 
what the nature of the mere intermission and exacerbation can 
be, independently of all periods; how a permanent disease can 
be so interrupted, how a derangement of such exceeding vio- 
lence as a severe fit of intermittent or Neuralgia can subside and 
leave the body in perfect health; still less, perhaps, believe that 
this is but a succession of diseases, and that the apparent health 
is real, or that the state x is not a permanent derangement of the 
nervous system. 

I willingly leave to others what appears to me a profundity 
of darkness: or rather I leave to posterity what I hope posteri- 
ty will discover, what at least, it will pursue, and through the 
road of philosophy, not words. Yet there is another doubt to 
be stated as to the periods of the compound intermittents, while 
I scarcely know what opinions have been formed respecting it, 
or whether we can dare to hazard one. I have already stated 
the forms of the double tertian, and need not repeat how this 
disease is distinguished from the quotidian; though I may re- 
mind the reader of the singular cases where one paroxysm is 
a common intermittent and the other a mere Neuralgia. The 
question is, whether this is one disease, or whether there are 
two distinct intermittents in the same person, acquired at diffe- 
rent times, and proceeding conjointly; and the same question 
may be asked as to the complications of type. I know not if 
any one is prepared to answer it; and if I fancy that I have 
traced the distinct origin of two several intermittents, from two 
distinct exposures to Malaria, in one person, at different and 
even distant times, afterwards proceeding conjointly as a double 
type, I cannot pretend to have convinced myself of the fact, and 
am far less desirous of attempting to convince others. And if, 
on the same ground, I have been familiar with one case, in- 
cluding two double quotidians, or a type where, while the first 
quotidian of each day was different from the succeeding, and 
while the two quotidians of the following were also different 
from each other and from both the preceding; and while I fur- 
ther knew that this patient commenced with a single quotidian 
and gradually accumulated all the others, including among them 
a Neuralgia, I am ready to believe whatever shall hereafter be 



MARSH FEVER AND NEURALGIA. 467 

determined on this subject; still looking to posterity, for the 
complete elucidation of a set of diseases, or of a disease, which 
I have but sketched, and very imperfectly; while I demand the 
indulgence which may fairly be claimed for a first attempt to 
extricate a long train of difficulties from their former confusion, 
and from the prejudices or ignorance under which they have 
hitherto been contemplated. 

Nor do I despair of posterity, nor that physic will yet, at 
some future day, become a far other science than it is; if much 
should still remain unattainable, to prevent it from ranking 
among the accurate sciences. It may be a just enough censure 
which ridicules its past philosophy or smiles at its present pre- 
tensions, equalled only by its imperfections. But to prophesy 
that this is to be its continuous and eternal fate, is as little pru- 
dent as it argues want of reflection. We have no reason to be 
surprised at the little progress which it made for centuries, when 
we consider what those centuries were, and examine what then 
was the state of philosophy, and the methods of pursuing sci- 
ence at large. 

Not to enter on an examination of the history of the sciences, 
or of the progress of the human mind from a not very distant 
period to our own day, it must be evident to every one who has 
at all considered this subject, that, if some time has passed since 
the true path of philosophy was pointed out, it long remained 
an almost untrodden one, and that a very few years have wit- 
nessed greater strides taken, and more solid steps assured, than 
almost a whole preceding century could have numbered. The 
natural history of the human body in health and disease, we 
may admit, is as yet almost nothing in real value: it wants even 
the skeleton on which a science could be engrafted: it possesses 
hardly a fundamental step to that end. But surely a subject so 
deeply interesting cannot for ever be neglected; it will even 
draw the attention of cultivators, from the mere necessity of 
action, and as other subjects shall approach to exhaustion or lose 
the interest of novelty. It will attract the attention of genius 
striving to open for itself new paths to fame, and, in truth, it is, 
even now, attracting new talent and new industry. 

And the success will be more rapid and certain than it could, 
ever yet have been, because of the increased attention bestowed 
on the accurate sciences, or rather, on all the sciences. Inde- 
pendently of all the aids which it must receive from increase of 
knowledge and accuracy in those, since no science can stand on 
its own independent investigations or its own separate basis, it 
promises to be pursued by minds, not only informed in th< 
sciences, in science at large, but trained in the habits Ol philo- 
sophical investigation and in the sound logic of things. This 
is a philosophy which will not bo cheate I ] ipty phra- 



465 STATE OP THE NERVES IN 

seology of physic, but. which will define its terms and adhere 
to them, will cease to be satisfied with words and will demand 
ideas, will search for evidence and compare analogies, will form 
solid inductions, and re-extend its generalizations backwards to 
new inquiries and new facts. 

These are the minds to which physic must look; and we are 
very far indeed, I hope, from being wanting in them, if, as 
yet, their labours are diverted by other subjects, prejudiced, 
too often, it may be, respecting what has been too long regard- 
ed as hopeless, while it is now too much also avoided, or ex- 
cluded, as professional. Professional, it may be; but assuredly 
it is a science of as universal concernment as any which philo- 
sophy is now cultivating; as deeply interesting to every man, 
it will not be doubted, as chemistry, astronomy, or mechanics, 
matter of the most intimate personal interest, as it is of rational 
curiosity. But to throw it back as a duty or a right into the 
hands of that profession to which it is a trade, will not prove 
the road to its effectual cultivation: while it is an unfortunate 
truth, on the contrary, but too well known to every candid and 
educated physician, that no readier means of obstructing its 
progress as a science could well be invented; as this has already 
operated, and daily operates, in forming obstacles to its progress. 

The utmost candour and mildness of judgment cannot deny 
that such is the fact, and that it cannot be otherwise. To thou- 
sands, to the vast majority, it is a mere trade, followed as a rou- 
tine; and, to not one among thousands, is it an object of science; 
to no one, perhaps, of merely scientific pursuit. And while 
this vast majority does nothing towards its improvement, the 
bad effects are not merely negative; as the mystery and the er- 
ror are fortified by the sanction of those thousands, and as those 
who, from education, from acquaintance with general science 
and habits of accurate investigation, would be competent to the 
inquiries under discussion, are excluded from the means of in- 
quiry. How very few persons of the requisite education there 
are, engaged in physic itself, compared to the multitude, is too 
well known, to those at least who are capable of the needful 
discernment: while, by a singular perversion of reasoning, it is 
the settled prejudice of the public, to reject, as physicians, those 
who have given the greatest proofs of possessing extensive ge- 
neral knowledge and powerful minds; thus depriving them of 
the means of investigation, with consequences to themselves, as 
to the science, which must be too obvious to name, and which 
that science must deplore. 

But it would be too easy to prolong these remarks beyond due 
bounds; and I must therefore conclude; adding to a mere wish 
as to the fact itself, a wish to believe that the day is not very- 
far distant, when the science of physic will become a sharer in 



IvIARSH EEVER AND NEURALGIA, 469 

that philosophical attention which it has scarcely or scantily yet 
received, from minds competent to pursue it as a science, and 
anxious as competent; expressing my further hope that, at some 
future day, the art of healing will become an art in the hands of 
philosophers, and not the trade of empirics; that while philoso- 
phy is labouring to inspire its principles into every artisan, this 
will not be the only department which it is content to view as 
a mechanical art, to be conducted mechanically, by artisans. 
And that it is thus viewed hy the entire public, that it is consi- 
dered, even by the educated public, by what are called rank and 
talents, universally, as a mere art and a mystery, and not a 
branch of science, is sufficiently proved, not merely by the facts, 
that neither abilities nor education are judged necessary for those 
who practise physic, but trmt every one considers himself compe- 
tent to conduct and understand it; that equal value, or often greater 
is attached to the trader in secrets, who does not even pretend 
to medical knowledge, to him who, often, it is well known, can 
scarcely read or write, to the utterly ignorant and base, to the 
unseen and unknown, and even to the long dead and buried em- 
piric, who cures diseases which he has not examined, and pa- 
tients whom he never saw and can never see, by remedies of 
which he knows nothing; and that the stamped box or bottle 
can supersede all knowledge and all examination of the patient 
or his disease. 



I have fully stated in the course of this essay, the reasons 
which compelled me to adopt an order (I should call it a disor- 
der,) in treating of the diseases which it includes, of which I 
did not approve: and I then expressed a hope that I might be 
able to sketch the form of some better arrangement. 1 have 
considered how this could be done, yet with not much satisfac- 
tion from any attempt that I have been able to make. The sub- 
ject is both intricate and deficient: the boundaries of what may 
be considered diseases and what may be viewed as mere symp- 
toms, are very indefinite; and while, further, many of them 
run into each other so as to defy a correct division, there are 
numerous probable blanks which, for want of sufficient experi- 
ence, I cannot supply. But almost any arrangement is prefer- 
able to none, or to that disorder under which I have already con- 
sidered the diseases in question; and I shall therefore, without 
further apology, submit the following tabular view, as a basis 
or sketch for future amendment or alteration, should the subject, 
as I have treated it, meet with that approbation from the pro- 
fession, of which my hopes are indeed but slender. 



( 471 ) 

9 

TABULAR VIEW. 

Of the Diseases appertaining to Marsh Fever and Neuralgia. 



MARSH FEVEJL 
continuous 
remittent 

Ephemera ~) 

Synocha > ? 

Synochus 3 

SINGLE on TERMINATING » 

CHRONIC OR RELAPSING 

anomalous and simulating: mte Intermittent/ 

2NTERMITTENT 

QUOTIDIAN 

i Double 

Tertian 

Double 

Quartan 

Double 

— Triple 

Quintan, &c. 
Single or terminating' 
Chronic or relapsing 

Anomalous and simulating. With local symptoms often 
more conspicuous than febrile ones; and chiefly so when 
chronic. Often deceptive in these cases, or mistaken for 
original or separate diseases. 

Terms from paralytic. 

Authorities. 

carotica < k ..... . Apoplexy — primary: repeated 

soporosa £ • ♦ < • Lethargy periodical 

comatosa Coma periodical 

Universal palsy — permanent 

Hemiplegica * . Hemiplegia "S 

Paraplegia £. permanent: periodical 

. .- . . ■. . . . 4 k * . . ► . . Local palsies j 

SPASMODIC. 



Epileptic* £;;:;::;:;;;;:;:; J^S, ns \«*y***: periodic! 

Cataleptica Catalepsy: periodical 

Hysterica Hysteria: irregular: periodical 

"Pertussis Spasmodic cough : periodical 

Asthmatica Asthma, Dyspnoea: periodical 

Straitguriosa irritability of bladder and strangury : periodical 

Palpitation of heart 



47x? TABULAE VIEW. 

SERvors miscellaneous. 

Aniens. Amentia quartana, . JtoZy] P €rmanent: Periodical ^ 
Hypochondriaca Hypochondriasis, permanent: periodical 

Vertigo, periodical:, transitory 
Cephalalgia Headachs, irregular: periodical 

Dyspepsia, irregular: periodical 

Deafness, periodical 

Amaurosis, periodical: durable 

Nervous disorders: undennabie 

Chlorosis 
Morbus Pannonic us Debility 

Atrophy 

Emetiea Vomiting, periodical, chronic: acute irregular 

Diarrhoea: periodical: permanent 
Menorrhagia, Amenorrhea, Dysmenorrhea 
Diabetes 

UTFIA3OTAT0RY. 

Pleuritica Pleurisy, permanent: periodical 

Hepatitis? 

Rheumatism 

general ~\ 

local r 

acute V permanent: periodical 

chronic k 

Arthritica of joints J 

of intercostal muscles: false pleurisy 

Nephralgia Nephralgia 

Catarrh: permanent acute: periodical, chronic 

Ischiatica Sciatica, periodical: permanent. ? Neuralgia 

Phthisis 
Hectic, false 
Urticata • ■ unknown to me, and not intelligible, or doubtful. 

BTSEXTERY, 

Acute 
Chronic. 

CHOLERA, 

Indian Cholera; if different 
Common Cholera. 

SUPPLEMENT. 

ENDEMICS SAID TO BE PRODUCED BY MALARIA. 

(moxfalcon axd others.) 
Scurvy 
Pellagra 
Bronchocele 
Ulcers 
Pickets 
Cretinage 
Hernia 
Varix 

Elephantiasis 
Asthma 
Angina 

(Edema of the lungs 

Visceral obstructions: and dropsy, as consequences 
Scrofula 
Phthisis 






TABULAR VIEW. 473 



NEURALGIA. 



Intermittent febrile Symptoms marked, obscure, or undiscoverable, 
or possibly not existing. 

PAINFUL. 

op assignable nekves. Pain acute: periodical or irregular. 

Spinal Marrow. As yet little known or observed. 

Nerves of face. Tic douloureux, in any part of the head, as 

well as of the face. 
Optic nerve. 

Of teeth. Toothach without caries. 

* Sciatic nerve. Sciatica. 

Anterior crural, in various parts, with various Neuralgiae. 

Spermatic nerve. 

Radial. In various parts, with various Neuralgia. 

— — Of fingers. 

Of toes. 

&c. Sec. Stc. Blanks to be filled: records not yet found. 

of unassignable nerves. Pain commonly less acute, or dull, or 
none:' periodical or irregular: very acute however in some 
cases. 

* Headach 

Common, confined to parts, or general. 
Intermitting. 
Hemicrania. 
Clavus. 
Y/andering or unfixed toothach; or face-ach. 

* Palpitation of heart. No pain. 
Palpitation of aorta, No pain. 
Palpitation of cceliac artery? 
Stomach pains? 

Colic — ? 

* Kidney and ureter. Decided Neuralgia: nephralgic pains. 
Bladder and neck. Irritability: stranguary; no pain, 
Rectum. 

Testicle. Acute pain. 
Palus. 

Cauda equina. Lumbago. 
Dr. Alderson .... Mamma. Acute pain. 
Knee. Pain various. 
Shin bone. Anterior tibial? considerable pain. 

inflammatory, with neuralgic pains of assignable or unassignable nerves: 
acute or dull: irregular or periodical. 

* LOCAL RHEUMATISM OF LIMBS. 

in muscles. 
in joints. 

UHEUMATISM OF 1IEAJ). 

in face. Rheumatic (inflammatory) headach, 
in jaw. Rheumatic toothach. 

60 



474 TABULAR VIEW • 

ophthalmia. Fixed or intermitting-. 

Acute. 

suppurating-. 

Inflammation of Iris. 

Chronic. 

Transferable. 

from i-sjuiiY. With inflammation, or not. 

from wounds or punctures oi nerves* any where, 
from blojod-Ietting. 

from amputation" 

from blows: anywhere. 
from ulcers: any where. 

from caries of teeth: carious toothach. 

from tumours, aneurisms, %c. 
from corns. 

neuralgic affectioits or glands. Irregular, or periodical. 

* Diabetes: periodical. 

Lacrymation: general: occasional, or periodical. 

— ; Of one eye: false-fistula. Periodical: Irregular 

* Salivation. 

* Diarrhoea. Uncertain: periodical: 

tertian: 

. quotidian. 

Semi catarrh. Irregular: periodical. 

cosrsrarrjiCES of neuralgia: during, or subsequent to the painful state, 

CEis-EIUL, 

* Mania. Irregular: periodical. 

— te:Lan : 

■ — quotidian. 

* Fatuity. Permanent: periodical. 

tertian. 

* Hemiplegia. 

* Nervous diseases. Indefinable in variety and number, 

partial. Local paralytic affections. 

numbness: any where. 

tingling: sensibility: facility of being affected 
by pressure, 

* Amaurosis. Permanent: periodical. 
Contraction of Iris. Permanent: periodical. 
Opacity of cornea. 

Cataract? 

Caries of teeth? 

Gum boils and abscesses. Irregular: periodical. 

N. B. As in the first division of this table, it is supposed that there are 
blanks yet to be filled in the whole. It cannot be given as a perfect enumera- 
tion; being founded solely on the author's own narrow eaperience. 

The affections marked with * have been unavoidably also enumerated under 
intermittent, since they occur in both; or else the exact character of the dis- 
ease is 3 under the present separation, unassignable. 



THE END, 






3^77-2 



Hi 




